The nursing health assessment course SHEKA SHEMSI (Assistant professor at Jimma university department of nursing, Jimma, Ethiopia

1. Cardio vascular System (CVS) Examination
By: Sheka shemsi(MSc)
Nursing health assessment course
4/6/2022 CVS EXAMINATION 1

2. CVS…….  Circulation through the heart is shown in the
diagram, which identifies the cardiac chambers,
valves, and direction of blood flow.
 Because of their positions;
o The tricuspid and mitral valves are often called
atrioventricular valves.
o The aortic and pulmonic valves are called
semilunar valves.
4/6/2022 CVS EXAMINATION 2

3. An overview of the CVS Examination
 The evaluation of the CVS includes
 a thorough health history,
 a detailed examination of:-
o the heart
o the peripheral arterial and venous circulations
 an appropriate laboratory studies.
4/6/2022 CVS EXAMINATION 3

4. Health history
Common or concerning symptoms of Cardiovascular Disease
 Dyspnoea:-shortness of breath (SOB) on exertion
 Chest pain:-which radiates to the left neck, shoulder and left upper arm
 Body swelling:-Which usually starts from the leg
 Palpitation:- Is subjective unpleasant perception of one’s own heartbeat
 Cough:- Which usually occurs at night (nocturnal)
 Syncope:-Is sudden episode of fainting related to hemodynamic derangement
Dyspnea: This is a state of shortness of breath (SOB) on exertion.
o But, it may occur at rest as the heart failure progresses.
o Also called difficult or labored breathing.
4/6/2022 CVS EXAMINATION 4

5. The degree of dyspnea is graded based on the NHA Class (NHAC):
Tab.1 New York Heart Association Functional Classification
Class I  No limitation of physical activity
 No symptoms with ordinary exertion
Class II  Slight limitation of physical activity
 Ordinary activity causes symptoms
Class III  Marked limitation of physical activity
 Less than ordinary activity causes symptoms
 Asymptomatic at rest
Class IV  Inability to carry out any physical activity without discomfort
 Symptoms occur at rest
SOURCE: Modified from The Criteria Committee of the NHAC.
4/6/2022 CVS EXAMINATION 5

6. o Paroxysmal Nocturnal Dyspnea (PND): Is type SOB that occurs during sleep.
 The patient suddenly wakes up due the SOB and then sits up or rushes to open
window/door to get fresh air.
o Orthopnea: Is type SOB that occurs during recumbent position.
 It is evaluated by the number of pillows that are used to relieve the symptom.
4/6/2022 CVS EXAMINATION 6

7. concerning symptoms of Cardiovascular Disease (CVD)……………..
Chest pain: Angina pectoris is a cardiac pain.
 It arises in the precordial area usually on the retrosternal region
 It radiates to the left neck, shoulder and left upper arm
 It has piercing, or squeezing character
 It is aggravated by exertion & relieved by rest
4/6/2022 CVS EXAMINATION 7

8. Physical Examination
 Instruments needed for CVS examination include:
 Stethoscope
 Penlight
 Centimeter ruler and tape measure
 Sphygmomanometer
 General Considerations
 The patient must be properly undressed above the waist.
 The examination room must be quiet to perform adequate auscultation.
4/6/2022 CVS EXAMINATION 8

9.  General signs of Cardiovascular Disease (CVD)
• Observe the patient for general signs of cardiovascular disease.
 Breathing pattern; for respiratory distress
 Signs of respiratory distress, such as tachypnea, flaring, and retractions, may be
associated with the client attempts to compensate for hypoxemia caused by a
chronic heart disease.
 Skin color: for cyanosis; the mucous membranes are usually pink.
 Lips: for cyanosis.
 Mouth and tongue: for central cyanosis.
 Eyes
 for pallor of the conjunctiva: indicates anemia
4/6/2022 CVS EXAMINATION 9

10.  Hands for edema: indicates poor venous return.
 Color of the palm: for cyanosis.
 Shape of the finger nail
 Clubbing of finger nail (concavity of finger nail means the angle is > 180o) suggests chronic
cyanosis or infective endocarditis.
 Capillary refilling time
 Checked by pressing tip of finger for a brief period then release the pressure.
 Normally the color returns immediately when the pressure is released.
 Capillary refill is normally < 2 seconds, indicating good circulation and perfusion of the tissues.
 Sluggish return of color up on releasing pressure suggests decreased peripheral circulation.
4/6/2022 CVS EXAMINATION 10

11.  Temperature and moisture
 Asses the temperature and moisture by using dorsum of the hand.
 Normally on palpation there is no temperature difference & it is warm and dry.
 Moist and cool hand may occur in decreased peripheral circulation.
 Legs
 for edema: indentation remains > 5 seconds after brief pressing
• + 1 (mild) +2 & +3 (moderate) +4 (severe edema)
• 2 mm 4-6mm > 8mm
• for varicose veins and ulcer
4/6/2022 CVS EXAMINATION 11

12. Components of Cardiovascular System Examination
A.Arterial System Examination
B.Venous System Examination
C.Precordial/ Cardiac Examination
1. Arterial System Examination
The important part of arterial system examination includes
 palpation of the pulses of the major arteries and
 measuring of the blood pressure.
4/6/2022 CVS EXAMINATION 12

13.  Location of the major arteries
 Major arteries are temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and
dorsalispedis.
☼ Pulse Rate: the radial artery is preferred. Pulse
classification based on the rate:
 Normal 60-100 beats/min
 Bradycardia < 60 beats/min
 Tachycardia > 100 beats/min
☼ Pulse Rhythm: Pulse classification based on rhythm:
 Regular - Regular
 Regular - Irregular
 Irregular - Irregular
☼ Pulse Volume (amplitude): Best checked on carotid arteries. Observe for carotid pulsation and volume. Pulse
classification based on volume:
 Feeble or weak, Normal ,Rebound
4/6/2022 CVS EXAMINATION 13

14. ☼ Radio femoral delay
 Radial artery & femoral artery are palpated symmetrically at the same time.
 Normally they are synchronize/symmetrical.
 In some obstructions there will be delay of femoral artery.
• E.g. Coarctation of aorta, occlusive aortic disease
• Measuring the Blood Pressure
 Assessment of blood pressure is important to detect conditions of hypertension or
hypovolemic shock.
 The patient should be seated and quiet for 3 to 5 minutes before the BP is taken.
4/6/2022 CVS EXAMINATION 14

15. 2. Venous System Examination
• Jugular Venous Pressure (JVP)
 Estimating the JVP is the most important part of venous system examination.
 It is a reflection of right atria pressure & known as central venous pressure (CVP).
 JVP examination is used to estimate CVP
.
• Distinguish the internal jugular vein from the carotid artery pulsation.
4/6/2022 CVS EXAMINATION 15

16. Steps for assessing the Jugular Venous Pressure (JVP)
1. Position the patient supine with the head of the table elevated 30O.
2. Adjust the angle of table elevation to bring out the venous pulsation.
3. Use tangential side lighting & look for rapid and double wave with each heart
beat
4. With elevation of the head identify the highest point of pulsation (HPP) in the neck.
5. Using a horizontal line from HPP then measure vertically from the sternal angle
4/6/2022 CVS EXAMINATION 16

17. Interpretation of JVP
Normally:
o JVP measurement should be < 3 cm above the sternal angle in a health adult.
o JV is distended in supine position and loud voice.
o But in shock patient JV is not seen even in supine position.
o Distention with elevation of the head or JVP measured at >4 cm above the sternal angle is
considered elevated JVP
.
o Indicates raised right atria pressure which is most often found in right ventricular failure
(RHF), fluid over load, tricuspid stenosis, or obstruction of superior vena cava.
 The way to report:
o JVP is 5 cm at 450 inclination with reference at sternal angle or an angle of louis.
4/6/2022 CVS EXAMINATION 17

18. 3. Precordial or Cardiac Examination
 Precordium is the part of the anterior chest wall which overlies the heart.
 The examiner should stand at the patient’s right side.
 For most of the cardiac examination, three positions are needed:
1. supine with the head of the bed or table elevated to about 30°,
2. turning to the left side, and
3. sitting & leaning forward
4/6/2022 CVS EXAMINATION 18

19. Techniques of Precordial Examination
1. Inspection of the Precordium
 Position the patient supine with the head of the table slightly elevated.
 Begin the heart examination by inspecting the precordium, or anterior chest.
A. Inspect the shape and symmetry of the anterior chest from the front & side views.
o The rib cage is normally symmetric.
 Precordial bulge which may indicate long standing cardiac disease.
 Bulging of the left side of the chest wall may indicate an enlarged heart.
 Previous scars over the chest wall
4/6/2022 CVS EXAMINATION 19

20. A. Observe for any chest/ precordial movement associated with the heart’s
contraction.
o Normally there is no an observable pulsation and heave or lift.
 Abnormal pulsations
 Multiple pulsation e.g. multi valvular lesions
 Quiet pulsation e.g. Pericardial effusion
 Heave, an obvious lifting of the chest wall during contraction, may indicate an
enlarged heart.
4/6/2022 CVS EXAMINATION 20

21. Location of the apical impulse
A. Location of the apical impulse, sometimes called the point of maximum intensity, is located where
the left ventricle taps the chest wall during contraction.
 When visible the apical impulse is normally seen or located in the left 5th ICS
 at or 1 cm medially to the LMCL or 7-9 cm laterally from MSL.
• In about half of the patients the apical impulse is invisible but it can normally be seen in thin
patient.
4/6/2022 CVS EXAMINATION 21

22. Palpation of the Precordium
 Place the entire palmar surface of your fingers together or the ball of your hand on the
chest wall to palpate the precordium.
 Systematically palpate the entire precordium to detect any parasternal pulsations,
heaves, or vibrations.
 to Identify the PMI (Point of maximal impulse)
a. Parasternal impulses
 Generally palpate the entire precordium using the ball of your hand to detect
parasternal impulses at the right & left interspaces, along the left sterna borders, & at
the apical area.
 In normal individuals parasternal impulse is not palpable & no any abnormal sensations
like vibrations, heaves or lifts.
4/6/2022 CVS EXAMINATION 22

23. a. Abnormal sensations
 Palpate the parasternal region at the same locations for abnormal sensations.
 Thrills (a palpable murmur)
 A thrill is a rushing vibration that feels like a cat’s purr.
 It is caused by turbulent blood flow from a defective heart valve and a heart murmur.
 Parasternal heave (lifting the ball of your hand or a pen when we put on the left parasternal area)
 It is the sensation of the heart lifting up against the chest wall.
 It may be associated with an enlarged heart or a heart contracting with extra force.
4/6/2022 CVS EXAMINATION 23

24. a. Identify the PMI (Point of maximal impulse):
 PMI is usually located at the same area of the apical impulse.
 Place the patient in the supine position elevating the trunk approximately 30-45 degrees.
 Using the palmar surface of your finger tips palpate the apex over the left precordium in the 4th,
5th, and 6th ICSs near the MCL to confirm the characteristics of the apical impulse for location and
diameter.
• Diameter
 Usually measures < 2.5 cm (1cm by 2cm) and occupies only one interspace.
 In the left lateral position, a diameter > 3 cm indicates left ventricular enlargement.
4/6/2022 CVS EXAMINATION 24

25. Displacement of PMI:
 Upward and to the left from pregnancy,
 Lateral displacement from cardiac enlargement in Congestive heart failure &
Cardiomyopathy ,
 Downward and lateral displacement of the apex below the 5th interspace in Left
ventricular dilation,
Mediastinal displacement from deformities of the thorax
4/6/2022 CVS EXAMINATION 25

26. Percussion of the Precordium:
 Percussion of the heart borders is rarely performed during PE.
 It has little significance in precordial examination.
 The borders of the heart are better identified by radiologic examination.
 (Note: often done by chest X-ray)
 Normally dullness in the 3rd, 4th, 5th, and possibly 6th left ICSs.
 To estimate cardiac size like cardiomegaly.
 Percussion is also done when one suspects dextro-cardia.
4/6/2022 CVS EXAMINATION 26

27. Auscultation of the Precordium:
 The stethoscope has two parts:-
o Diaphragm:
 Preferred to auscultate high pitched sounds e.g. S1, S2, murmurs of aortic & mitral
regurgitation.
 Should be pressed firmly against the chest.
o Bell:
 Preferred to auscultate low pitched sounds e.g. S3, S4, and the murmur of mitral
stenosis.
 Applied lightly, with just enough.
4/6/2022 CVS EXAMINATION 27

28. Areas of auscultation
o These areas are named for the valve producing the sound.
A. Aortic area— is the 2nd ICS to the right of the sternum.
B. Pulmonic area— is the 2nd ICS to the left of the sternum.
C. Erb’s point— 3rd ICS to the left of the sternum.
D. Tricuspid area (right ventricular or septal area) — is the 4th & 5th ICS to the left of the sternum.
E. Mitral area (left ventricular or apical area) — is at the apex
4/6/2022 CVS EXAMINATION 28

29.  Sequences of auscultation
o The auscultation sequence is started using the diaphragm of stethoscope to listen at all the auscultatory areas
(progress from the base of heart moving from right 2nd ICS to the left 2nd ICS then down to the left lower
border to the apex).
• Then with the bell of the stethoscope listen along the lower left sterna border in the left 4th & 5th ICS then listen
at the apex
 Position of the patient for heart auscultation
a. Position the patient supine with the head of the table slightly elevated(to auscultalteby diaphragm).
b. Ask the patient to roll partly onto the left side while you listen in the left 4th & 5th ICS and at the apex with bell
bell of the stethoscope.
 Bring the left ventricle close to the chest wall
 Accentuates (brings out) a left-sided S3, S4 and murmur of mitral stenosis.
4/6/2022 CVS EXAMINATION 29

30. a. Patient to sitting up, leaning forward, exhaling completely, and stop breathing in
expiration while you listen for the murmur of aortic regurgitation.
 With the diaphragm of the stethoscope, listening along the left sternal border
and at the apex, pausing periodically so the patient may breathe
 Accentuates (brings out) murmur of aortic regurgitation and pericardial
friction rub.
4/6/2022 CVS EXAMINATION 30

31. Heart sounds
 During auscultation focus on: normal, abnormal, and extra or additional heart sounds
1. Normal heart sounds
• The sound resembles the pronunciation of lub-dub.
a. S1 (the first heart sound):
 S1 results from closer of atrioventricular valves (tricuspid/mitral valves).
 Normally S1 is louder at the apex (in the tricuspid & mitral areas) and soft at the base of the heart.
 This signal the onset of systole.
 Key findings:
 S1 is loud in: mitral stenosis, tachycardia and hyper-dynamic circulation like e.g. anemia
 S1 is soft (muffled) in: mitral regurgitation, bradycardia and LVF
4/6/2022 CVS EXAMINATION 31

32. a. S2 (the 2nd heart sound):
 S2 results from closer of the semilunar valves (aortic and pulmonic valves).
 Normally S2 is louder at the base (aortic & pulmonic area) but soft at the apex.
 Key findings:
 S2 is loud: in systemic and pulmonary hypertension.
 S2 is soft: in aortic and pulmonic regurgitation.
Extra or Additional heart sounds (S3 and S4)
 These extra or additional heart sounds are low pitched sounds.
 They occurs during diastole.
 If either S3 or S4 is very loud it is often heard as gallop/triple rhythm.
4/6/2022 CVS EXAMINATION 32

33. S3 (3rd heart sound or ventricular gallop):
 S3 is auscultate using bell of stethoscope because it is low pitched sound.
 S3 occurs during diastole as result of rapid ventricular filling.
 It is also caused by overload.
 S3 may be heard in the tricuspid & mitral areas following S2 sound.
 S3 is best heard when the client is in the left lateral position, and the sound resembles the pronunciation of lub-
dub-by.
 It is normal in children and young adult.
 It occurs abnormally in:
 patients with heart failure
- left sided heart failure - S3 heard best in mitral area
- right sided heart failure - S3 heard best in tricuspid area
4/6/2022 CVS EXAMINATION 33

34. S4 (4th heart Sound or atrial gallop):
 S4 is auscultate using bell of stethoscope because it is low pitched sound.
 S4 occurs during forceful atrial contraction against a stiffened ventricle e.g. due to aortic
stenosis or hypertensive heart disease.
 It results also from resistance to ventricular feeling in a condition such as
 Cardiomyopathy, and Systemic and pulmonary hypertension.
 S4 may be heard in the tricuspid and mitral areas before S1 sound.
 S4 is best heard when the client is in the supine position, and the sound resembles the
pronunciation of le-lub-dub.
 S4 can be a normal sound in some older patients and trained athletes especially after
exercise.
4/6/2022 CVS EXAMINATION 34

35. Summation Gallop:.
• simultaneous occurrence of S3 & S4 is called summation gallop
Other abnormal sounds heard on auscultation
• Murmur:
 Murmur is abnormal sound (swishing or blowing sounds) heard in systole or diastole, which occur due to
“turbulence” of blood flow through a valve.
 Murmur is distinguishable from heart sounds by their longer duration.
 Murmurs are prolonged series of auditory vibrations.
 Position to be used to auscultate murmur
 Sitting, leaning forward to listen along the left sterna border down to apex
 Left side lying position to listen at the apex.
4/6/2022 CVS EXAMINATION 35

36. Murmur may occurs B/c of:
1. Increased velocity of blood (e.g. Exercise, thyrotoxicosis)
2. Decreases velocity of blood (e.g. Anemia)
3. Structural defect in the valves or an unusual opening occurs in the
chambers (e.g. valvular lesions)
4/6/2022 CVS EXAMINATION 36

37. The intensity of a murmur is graded I to VI.
Grade Volume Thrill
1/6 Very faint (weak); barely heard in a quiet room No
2/6 Quiet, but heard clearly and immediately after placing the stethoscope on the
chest
No
3/6 Moderately loud No
4/6 Loud (Louder than grade 3) Yes
5/6 Heard with the stethoscope partially off the chest Yes
6/6 Heard with the stethoscope completely off the chest Yes
4/6/2022 CVS EXAMINATION 38

38. Pericardial friction rub
 It is a leathery (rubbing) sound heard in systole or diastole, which suggests
pericardial inflammation (Pericarditis).
 Caused by abrasion of the pericardial surfaces during the cardiac cycle
 Can be heard best using the diaphragm of the stethoscope, with the patient
sitting up and leaning forward
4/6/2022 CVS EXAMINATION 39

39. THANK YOU
4/6/2022 CVS EXAMINATION 41