10 Focused Assessment – Cardiovascular System

Learning Objectives

At the end of this chapter, the learner will:

  1. Obtain health history related to the heart and peripheral vascular systems.
  2. Perform physical assessment of the heart and the peripheral vascular system using correct techniques.
  3. Document findings of cardiac and peripheral-vascular assessment.

I. Overview of the Cardiovascular System

The assessment of the cardiovascular system will include examinations of the peripheral vascular system by assessing the color, temperature, edema, capillary refills, and peripheral pulses and examinations of the heart by inspecting, palpating and auscultating the landmarks of the heart.

II. Anatomy and Physiology

Click the link below to review anatomy and physiology of the circulatory system. In the assessment process, you will need to apply your knowledge of the A & P to the heart and peripheral vascular system.

Knowledge Check

III. Medical Terminology

Angina pectoris chest pain, a result of myocardial ischemia
Arteriosclerosis (Atherosclerosis) formation of plaques of fatty material within arterial walls
Bradycardia slow heart rate
Bruit a blowing sound heard in auscultation  over a peripheral vessel or an organ.
Capillary Refill Time (CRT) time required for return of color after application of blanching pressure to a distal capillary bed
Cyanosis bluish-gray discoloration of the skin
Diastole period of time within the cardiac cycle in which ventricles are relaxed
Ecchymosis discoloration of skin caused by leakage of blood into the subcutaneous tissue
Embolus blood clot or foreign object in the circulatory system
Heart murmurs a blowing, whooshing, or rasping sound heard during a heartbeat which is caused byturbulent blood flow through the heart valves or near the heart.
Hypertension high blood pressure
Korotkoff Sounds series of sounds that correspond to changes in blood flow through an artery as pressure is released
Myocardial infarction heart attack
Palpitations sensations of pounding or racing of the heart
Pitting Edema an indentation remains after the swollen skin is pressed
Pulse Pressure difference between systolic and diastolic pressure
Prehypertension an elevated systolic blood pressure of 120-139 mmHg and diastolic 80-89 mmHg
Systole period of time within the cardiac cycle in which ventricles contract
Tachycardia rapid heart rate
Thrombus blood clot
Deep Venous Thrombosis (DVT) formation of a blood clot in a deep vein

Knowledge Check

IV. Step by Step Assessment

  • Perform hand hygiene.
  • Check room for contact precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Assemble equipment prior to starting exam.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Apply principles of asepsis and safety.
  • Check vital signs.
Additional Information
1. Conduct a focused interview related to cardiovascular and peripheral vascular disease. Ask relevant questions related to chest pain, palpitations, shortness of breath (dyspnea), cough, edema, fatigue, cardiac risk factors, leg pain, skin changes, swelling in limbs, history of past illnesses, history of diabetes.

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)
Cyanosis is an indication of decreased perfusion and oxygenation.

To check capillary refill, squeeze nails or pads of fingers until they blanche; release compression and observe how many seconds the original color returns. Normal is 2 seconds or less.

Assess capillary refill on bilateral lower legs.


Assess capillary refill
Assess capillary refill bilateral lower legs

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.

Clubbing fingers
Clubbing fingers

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.

Assess for CWMS
Assess calf for CWMS

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

3. Auscultate:

Aortic/Pulmonic/Erb’s point/Tricuspid/Mitral

Auscultate apical pulse for one minute. Note the rate and rhythm.



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

Aortic Area – 2nd ICS on the right sternal border.

Pulmonic Area – 2nd left ICS

ERB’s Point – 3rd left ICS

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

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

Auscultation landmarks

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.

4. Palpate:

  • The ball of the hand (at the base of the fingers) 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.
  • The finger pads are more sensitive in detecting pulsations. Use the finger pads of index and middle fingers and apply light pressure on the pulsation site. 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.

  • To check skin turgor, use the thumb and index fingers to pinch an area of the skin and release it. It should instantly return to place.
  • To check edema, press down the skin and release the pressure, the skin normally will return to place right away. Assessing Edema. When the indentation of the thumb or any fingers remain in the skin, it is pitting edema.  Documenting Pitting Edema
5. Report and document assessment findings and related health problems according to agency policy. Accurate and timely documentation and reporting promote patient safety.

Note: Click all hyperlinks to access more details. Copyrighted materials used with permission of the author, A. Chandrasekhar, Loyola University Medical Education Network.

V. Documentation of Assessment Findings

A sample of the narrative documentation:

A & Ox4, patient appears comfortable in bed. Chest is symmetrical expansion with respiration, no scars. No cardiac heaves or lifts. No thrills is palpated. PMI noted at fifth intercostal space and midclavicular line. Normal S1 and S2 with regular rate and rhythm. No rashes, swelling, color change, or cyanosis in arms or legs. No clubbing in fingernails. Capillary refill is < 2 sec. Hands and feet pink and warm to touch. No pitting edema in feet.

VI. Related Laboratory and Diagnostic Procedures/Findings

Some blood tests related to the cardiovascular system are seen frequently, for example, cholesterol tests which measure the levels of fat and cholesterol in the bloodstream. When serum cholesterol are high, the patient will be at risk for cardiovascular problems.  When there is an abnormal finding in the physical assessment,  the patient may need to have additional diagnostic procedure(s) to further identify a potential cardiovascular disease. These diagnostic cardiac tests could be non-invasive, such as electrocardiogram (ECG or EKG), uses to record the electrical activity of the heart; Holter Monitoring (or Ambulatory ECG), can record the electrical activity during daily activity; chest X-ray, examines the size of the heart; echocardiogram, uses high-frequency sound waves to view the size/structure/motion of the heart; exercise stress test (or treadmill test), can be used to examine the heart function while exercise on treadmill. Diagnostic tests could be invasive, such as  cardiac catheterization or coronary angiogram to check heart abnormalities or coronary artery problems.

A more detailed overview of different cardiac diagnostic tests is available at: Cardiac Diagnostic Tests

VII. Learning Exercises

VIII. Attributions and References

  • Busti, A. J. Pitting edema assessment. EBM Consult. September 2016. DOI: https://www.ebmconsult.com/articles/pitting-edema-assessment
  • Chandrasekhar, A. Screening physical exam. March 2006. http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/pstep75.htm
  • Desherinka. File:Acopaquia.jpg. (2014, March 4). Wikimedia Commons, the free media repository. Retrieved 23:54, August 29, 2019 from https://commons.wikimedia.org/w/index.php?title=File:Acopaquia.jpg&oldid=118072980.
  • Doyle, G. R. & McCutcheon, J. A. Step by Step Checklist adapted from https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/
  • Gibson, M. & Zorkun, C. Heart sounds. June 2015. DOI: https://www.wikidoc.org/index.php/Heart_sounds
  • Khan Academy: Circulatory system and the heart by Sal Khan. https://www.khanacademy.org/science/health-and-medicine/circulatory-system/circulatory-system-introduction/v/circulatory-system-and-the-heart
  • MedlinePlus. Cardiac diagnostic tests. US National Library of Medicine. DOI: https://medlineplus.gov/hearthealthtests.html
  • Textbook of Cardiology. Physical examination. December 2012. DOI: https://www.textbookofcardiology.org/wiki/Physical_Examination%23Cardiac_Auscultation


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Health Assessment Guide for Nurses Copyright © by Ching-Chuen Feng; Michelle Agostini; and Raquel Bertiz is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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