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UWE Bristol
Cardiovascular system examination
Anna Neary
Cardiovascular system examination
Introduction
Prior to undertaking this learning activity you should have
completed the learning activities: An introduction to Consultation
models and History taking.
This activity looks at examination and assessment of the
cardiovascular system as a crucial component of a systematic
patient assessment.
In this activity, you will:
•
•
•
•
•
Explore the anatomy of the heart
Consider a systematic approach to cardio-vascular
examination
Explore the elements of a general survey
Consider peripheral pulses
Determine the skills required to perform an examination i.e.
inspection, palpation and auscultation
Cardiovascular system examination
The Heart
The heart has four chambers and four valves that pump blood to
the pulmonary and systemic circulation.
The left side of the heart comprising of the left atrium and ventricle,
receives blood from the lungs and pumps blood to the tissues (high
pressure).
The right side comprising of the right atrium and ventricle receives
blood from systemic veins and pumps blood to the pulmonary
system (low pressure).
Cardiovascular system examination
The valves of the heart and their function
The heart has four valves:
•
The Atrioventricular valves, the tricuspid valve on the right
and the mitral on the left.
•
The Pulmonary valve between the right ventricle and
pulmonary artery, this is a semi-lunar valve.
•
The Aortic valve between the left ventricle and the aorta, this
is a semi lunar valve.
All of the valves, when functioning normally, act as one-way valves,
allowing blood to flow either from one chamber to another, or
allowing blood to flow out of the heart, in only one direction. The
valves control the flow of blood through the heart by opening and
closing during the contractions of the heart.
All of the valves open and close passively as a result of pressure
changes within the four chambers and the great vessels.
Cardiovascular system examination
The heart as a pump
Systole: the ventricles contract:
•
The right ventricle pumps blood into the pulmonary
arteries, the pulmonic valve is open.
•
The left ventricle pumps blood into the aorta, the
aortic valve is open.
Diastole: the ventricles relax:
•
Blood flows from the right atrium → right ventricle, the
tricuspid valve is open.
•
Blood flows from the left atrium → left ventricle, the
mitral valve is open.
Cardiovascular system examination
The vascular system
The vascular system is made up of many arteries, arterioles, veins,
venules and capillaries, their function is to deliver oxygen, nutrients
and substances to the body’s cells and remove waste products.
An adults circulating blood volume at any one given time is
between 4 to 6 litres of blood.
The pulse
A pulse is an arterial pressure wave, generated from the pumping
action of the heart. These can be felt at a variety of locations
throughout the body. When feeling for the pulsation in a number of
locations you are pressing the artery against bone, and this will
require firm pressure. The exception is the carotid artery.
Cardiovascular system examination
Systematic examination
There are three aspects to consider when carrying out a systematic
examination:
LOOK:
inspect
FEEL:
palpate and percuss
LISTEN:
auscultate
Cardiovascular system examination
General Survey
First you need to take time to look at your patients overall
appearance, remembering the importance of basic assessment i.e.
airway, breathing, circulation, disability and exposure and move on
only when there is no immediate intervention in these areas. Also
consider whether your patient appears to be alert or confused or
aggressive. You will need to check their blood pressure in both
arms, heart rate, respiratory rate and pulse. Look at hands, check
for signs of cyanosis and any nail deformities.
Does you patient look pale, sweaty are there any signs of cyanosis,
are there signs of any shortness of breath?
Think about other factors, is your patient thin or obese are they
anxious are there any abnormal facial features e.g. Down’s
syndrome are linked with congenital heart disease. Check for
peripheral oedema. This survey will then become your opening
words for the examination section in your documentation.
Cardiovascular system examination
Below are some of the hand abnormalities that you may find with
patients who have cardio-vascular disease.
•
Clubbing – swelling of the soft tissue at the nail base, can be
due to hypoxia and congenital heart disease, lung disease,
inflammatory bowel disease and malignancies.
•
Terry’s nails – transverse bands of white that cover the nail,
pink at the distal aspect, this commonly associated with liver
disease.
•
Koilonychia – this is thin spooned shaped nails with edges
turning upwards, this is associated with anaemia, chronic
infections, Raynaud’s disease and malnutrition.
•
Cool skin - can indicate poor cardiac output and tissue
perfusion.
•
Splinter haemorrhages - fine vertical lines in the nail can be
associated with bacterial endocarditis.
Cardiovascular system examination
Inspection
You need to look at the chest wall anterior and posterior. This will
require that you undress your patient. Look at the shape of the
chest, also their work of breathing, are there any scars, bruising or
pacemaker sites, can you see any visible pulsations? Does your
patient appear pale and/or central cyanosed?
When looking at the movement of the chest you need to check
symmetry and pulling in of the chest.
Think about the underlying structure within the chest, look for any
strong outward thrust of the chest wall that occurs during systole,
this is called a heave.
Cardiovascular system examination
Signs and symptoms of cardiovascular
conditions
The signs and symptoms you may observe in a patient with a
cardiovascular condition are:
•
Shortness of breath
•
Pallor
•
Confusion
•
Cyanosis of lips and peripheral cyanosis
•
Chest pain
•
Clubbing of finger nails
•
Anxiety and distress
•
Tremor
•
Sweating
•
Malar flush
•
Corneal arcus
•
Xanthomata and/or xanthelasma
•
Petechial haemorrhages
Cardiovascular system examination
Palpate
Palpate the anterior and posterior chest wall. This requires gentle
touch so that any pulsations or other findings are not missed. The
ball of the hand and the finger tips are placed over the precordium
to find a apical beat and the flat of the hand is placed over the
chest to feel for any heaves or thrills. This will feel like a purring
cat. Check for tenderness while you are palpating.
It is important to note that the apical beat can be difficult to locate in
an obese patient or a patient with a thick chest wall. Asking the
patient to roll slightly over onto their left side or lean forward can
move the heart slightly anteriorly making it easier to feel.
Cardiovascular system examination
Capillary refill
Assess capillary refill, centrally or peripherally.
Apply pressure for 5 seconds, then observe the blood flow back
into the finger or chest wall it should return within 2 seconds, this is
a normal capillary refill time. It should be recorded as CRT < (less
than) 2 seconds or CPT > (greater than) 2 seconds.
Cardiovascular system examination
Palpate pulses
•
Palpate pulses
•
Count beats per minute
•
Assess quality and regularity of pulse.
•
Never check the both carotid arteries
together, check one at a time, pressing
too firmly will cause you patient to faint.
•
Click on thumbnails for site name
Bilateral
radial pulses
Bilateral brachial
pulse
Bilateral carotid
pulses
Cardiovascular system examination
Auscultation
•
•
•
•
•
Listen at 5 points with the patient at 45 degrees.
Aortic (2nd Intercostal space, Right Sternal Boarder)
Pulmonary x 2 (2nd ICS, LSB and 3rd ICS LSB)
Tricuspid (4th ICS, LSB)
Mitral (5th ICS, LSB)
You will here “lub” “dub” throughout all 5 points however, the first
heart sound is “lub” and is caused by the closure of the mitral and
tricuspid valves and is heard loudest at the apex of the heart (M).
The second heart sound is “dub” and is caused by the closure of
the pulmonary and aortic valves and is heard loudest on the right
(aortic) and left (pulmonary) sternal edge (A and P).
There are many heart sounds that can indicate abnormalities within
the heart. Click on the link and then listen to both recordings of
Heart Sounds.
Cardiovascular system examination
Summary
You have now reached the end of this activity. Here is a summary
of the key points:
•
It is important to know the anatomy of the heart prior to any
examination of the cardio-vascular system.
•
It is essential to examine the cardio-vascular system using a
systematic approach i.e. general survey, inspection, palpation
and auscultation.
•
It is important to have heard normal heart sounds on
auscultation so that abnormal heart sounds can be
differentiated.
Cardiovascular system examination
References
•
Douglas, G, Nicol, F and Robertson, C (2009) Macleod’s
Clinical Examination. Churchill Livingstone
•
Hogan-Quigley, B, Louise Palm, M, Bickley, L (2012) Bates’
Nursing Guide to Physical Examination and History Taking.
First Edition. Lippincott, Williams and Wilkins.
•
Rushforth, H (2009) Assessment made incredibly easy. First
UK Edition. Lippincott, Williams and Wilkins.
•
Tortora, G and Derrickson, B (2010) Essentials of anatomy
and physiology. Wiley Plus
Cardiovascular system examination
Guided learning (Duration: 2 hours)
As part of your guided study throughout these activities you are
required to keep a record of the patient’s documentation
(anonymous) and also reflect on your own consultation style.
1.
Identify a patient in practice and under the supervision of an
Advanced Nurse Practitioner or doctor, watch a cardiovascular examination and then perform a cardio-vascular
examination. Use the templates provided as an aid memoir.
2.
Discuss your findings with the ANP or doctor.
3.
Research common cardio-vascular conditions, Write a
reflective piece of work about a patient you have seen and the
guidelines you have learnt. The websites cardiovascular
disease and prevention of cardiovascular disease will help
your research.
4.
You will also be able to attend a day long face to face skills
workshop to complement this learning activity.
Cardiovascular system examination
Introduction
Prior to undertaking this learning activity you should have
completed the learning activities: An introduction to Consultation
models and History taking.
This activity looks at examination and assessment of the
cardiovascular system as a crucial component of a systematic
patient assessment.
In this activity, you will:
•
•
•
•
•
Explore the anatomy of the heart
Consider a systematic approach to cardio-vascular
examination
Explore the elements of a general survey
Consider peripheral pulses
Determine the skills required to perform an examination i.e.
inspection, palpation and auscultation
Cardiovascular system examination
Introduction
Prior to undertaking this learning activity you should have
completed the learning activities: An introduction to Consultation
models and History taking.
This activity looks at examination and assessment of the
cardiovascular system as a crucial component of a systematic
patient assessment.
In this activity, you will:
•
•
•
•
•
Explore the anatomy of the heart
Consider a systematic approach to cardio-vascular
examination
Explore the elements of a general survey
Consider peripheral pulses
Determine the skills required to perform an examination i.e.
inspection, palpation and auscultation
Cardiovascular system examination
Introduction
Prior to undertaking this learning activity you should have
completed the learning activities: An introduction to Consultation
models and History taking.
This activity looks at examination and assessment of the
cardiovascular system as a crucial component of a systematic
patient assessment.
In this activity, you will:
•
•
•
•
•
Explore the anatomy of the heart
Consider a systematic approach to cardio-vascular
examination
Explore the elements of a general survey
Consider peripheral pulses
Determine the skills required to perform an examination i.e.
inspection, palpation and auscultation