v

1. Colleen duManoir
Revised 2017 by
Kari Shipley, RN , BSN

2.  Cardiac RN competencies
 Charting
 History Taking
 CV Physical Examination
1. Inspection
2. Auscultation
3. Palpation

3. • BP • Rhythm
interpretation
• Skin colour
• Diaphoresis • Peripheral
pulses
• JVD
• Peripheral and
central
cyanosis
• Shortness of
breath
• Edema
• Heart sounds • Lung sounds • O2 Saturation
Performs focused cardiac assessment:

4. 4

8.  Ask open-ended questions
Avoid “yes” / “no” questions
 Ask direct questions
Avoid leading questions
Ask “PQRSTA” questions [CP and other
symptoms]
❥P = Provokes / Palliates
❥Q = Quality (Dull, sharp, burning etc.)
❥R = Region / Radiates
❥S = Severity (Scale of 1 to 10)
❥T = Timings (onset, duration, frequency)
❥A = Associated symptoms

9.  Chest Pain is the most common presenting
complaint for cardiologists
◦ Main concern is to determine whereto the patient is
experiencing stable angina, or ACS (unstable
angina, NSTEMI or STEMI) chest pain classified as
typical for angina, atypical for angina or non cardiac
 Differential Diagnosis: Broad and include
cardiac and non cardiac conditions -> see
next slide

10.  Aortic Dissection
 Pericarditis
 GERD
 Peptic Ulcer Disease
 Esophageal spasm
 Biliary Colic
 Costochondral syndrome (inflammation of costal
cartilage)
 PE
 Pneumonia
 Plueritic
 Pneumothorax

11.  Quantified by NYHA
 Dyspnea : Can be indicative of Heart failure, atrial
fibrillation, ACS or valvular heart disease
 SOB with orthopnea or paroxysm nocturnal
dyspnea is suggestive of heart failure or left
sided Valvular disease
 Associated symptoms such as fatigue and
decreased exciricise tolerance may suggest
cardiac cause


12. • Dizziness and syncope common CV complaint
• Rhythm disorders (tach and brady), structural heart
disease (AS/MS that limit LV outflow)
• Hypertrophic CM: syncope that occurs during or just
after suggest presence of reduced outflow
• Syncope associated with palpations: suggests
tachyarrhythmia
• Syncope with lightheadness and nausea following
diaphoresis suggest neurocardiogenic cause
(vasovagal)
• Ominous: syncope with abrupt onset without
warning, prolonged unconsciousness, and injury as
a result of syncope (high risk cause - malignant
arrhythmia)

13.  Cardiovascular
System
Head-to-Toe Assessment

14.  Stand on right side
 Ensure quiet room
 Position patient comfortably on back
 Ensure privacy & quiet
 “Bad form” to listen through clothing – too
much impedance
 If chest hair coarse & dry – wet hair to 
friction under stethoscope

15.  A multisensory experience that requires
integration of:
Inspection
Auscultation
Palpation
 When performed correctly most cardiac
abnormalities can be accurately detected

16.  Height & weight
 General development & nourishment
 Head, Neck, Eyes, Teeth
 Surgical scars or implanted devices
 Chest wall deformities (eg. Marfans)
 Perfusion (acute vs chronic)
-Skin color, cyanosis, nailbeds
 Peripheral Edema, emboli
 Skin integrity (arterial versus venous insufficiency)
 JVP/JVD
 Non verbal communication (Is the patient
experiencing pain, fear or anxiety?)

17.  Visually inspect the
head starting with the
eyes
 The abnormality seen
here is referred to as
xanthelasma indicative
of
hypercholesterolemia

18.  corneal arcus can be
normal part of the
aging process but
can also be
predictive of
hypercholesterolemi
a

19. Sclera edema
related to rapid
fluid resuscitation
and or poor
nutritional status in
chronic illness

20.  Dental carries and
poor oral hygiene
can be a source of
infection causing
endocarditis.
 Inspect the native
teeth but also the
palate of denture
wearing patients

21.  Have the patient lay supine with HOB raised or
sitting
 Apex impulse may be visualized on a
physically fit patient at the 5th ICS medial to
the MCL
 Note any pulsations (outward movement)
other than at the PMI
 Note any retractions (inward movements)
especially if the patient has had trauma
 Paradoxical movement of the left anterior
precordium is suggestive of LV aneurysm (as
apex contracts aneurysm bulges, paradoxical
movement)

22.  Nailbeds
◦ Cyanosis
◦ Capillary refill
Delay > 3 sec
= poor arterial perfusion
 Skin temperature and moisture

23. Cyanosis
Peripheral Central

24.   flow to extremities (tips of nose, ears, distal
extremities)-acutal arterial oxygen saturation may
be normal
 Exposure to cold,  CO r/t HF or shock
 As Hbg , palms more pale
 If anemia severe, creases in palms more pale

25. If prolonged,
sign of
arterial
insufficiency
(low CO or 
volume)

26.  Decreased arterial oxygen saturation
 Involves trunk and mucus membranes,
tongue, lips
 Causes: Congenital heart disease, CHF,
Valvular heart disease, MI

27.  Due to chronic hypoxemia
◦ Often Congenital heart disease
 Enlargement terminal phalanges
 Nailbed angle > 180° (N=160°)
 Spongy & floating nailbeds
 May be sign of congenital heart
disease or chronic hemoglobin
desaturation

28. Splinter
hemorrhage
Oslers
nodes
Janeway
lesions
Conjunctival
hemorrhage

29.  Location
 Extent
 Severity

30.  Pressure over bony
prominence
 Indentation lasting
> 5 minutes
  sacrum for
dependent edema if
not ambulatory
 Na or H2O retention
or Rt. Heart failure
 Anasarca =
generalized edema-
can be multi-system
 Sacral Edema

31.  Range: 0 to 4+
 4+ severe:
> 1 inch
2 to 5
minutes to
return to
baseline

32.  Allergic edema (angioedema)

33.  Decreased pulses
 Skin cool, pale, shiny
 Pain in legs and feet
 Ulcerations occur in area around toes and heel
 Foot turns deep red when dependent
 Nails may be thick and ridged.
 Resting limb pain
 Numbness, tingling
 intermittent claudication (pain with excecise)
 Prolonged tissue malnourishment
 Thickened nails
 Hairlessness
 Shiny taut skin
 Skin ulcers

34.  Pitting edema
 Ulcerations occur around ankle
 Pulses present but difficult to find because of
edema
 Foot may be cyanotic when dependent
 Brownish pigmentation
 From chronic obstruction or incompetent
valves in the veins

36.  At risk for DVT
 Not suitable
conduits for
bypass grafting

37.  The jugular venous pressure is an indirect
measurement of right sided heart pressures
 There are no valves entering the heart and the
RIJ is in direct alignment with the RA;
therefore, pressure from the right atrium can
be assessed in the RIJ
 Normal is <3-4 com ASA

38. Steps:
1. ↑ HOB (30 degrees)
2. Place small pillow under the neck to relax neck muscles
3. Turn head slightly away
4. Shine light from the side
5. Assess highest point of pulsation (use previous slide to determine jugular
versus carotid pulsation)
6. Extend pen horizontally to connect with ruler sitting on the sternal angler
7. Normal is 3-4 cm ASA

39. Carotid pulse
 Palpable
 Single wave
 Strong thrust
 Not affected by
inspiration
 Not affected by
body position
 Clavicular pressure
has no effect
Jugular pulsation
 Not palpable
 Consists of 3 waves
 Undulating or rolling
 Pulsation decreases
with inspiration
 Pulsation changes with
position
 Clavicular pressure
may increase the
prominence of
pulsations

40.  https://www.youtube.com/watch?v=lBPvJpaQ
WC4

41. 6/6/2020 41
 RV failure
 Fluid overload
 Increased CO states
 Pericardial constriction
 Pericardial tamponade
 Tricuspid valve disease

42. Severe right
sided heart
failure can
cause
abdominal
ascites

43. Cardiac auscultation is a
fundamental yet
exceedingly difficult-to-
master clinical skill.
Seyal. (2007).JAMA, 297, 217-218.
2. Auscultation

44. 6/6/2020 44

45.  A modern stethoscope consists of
two earpieces connected by
tubing to a chest piece which
usually has both diaphragm and
bell attachments.
 Earpieces should be angled
forwards to match the direction
of the practitioner's external
auditory meati
 Warm the room and the
stethoscope

46. Diaphragm
 High frequency sounds
 Systolic murmurs
 S 1 & S 2
 Ejection clicks
 Opening snaps

47. Bell
 Low-pitched sounds
 Diastolic murmurs
 S3 & S4
 Bell with applied pressure
behaves like diaphragm

48.  Cardiac assessment is
best done in the
supine position with
the HOB at 30-45
degrees
 Left lateral side lying
position is also good and
easiest for in-house
patients (heart falls
forward and against the
chest wall)
 Abnormal heart sounds
are rarely heard with the
patient in a supine
position

49.  Left lateral side lying
Positioning
❥Ask patient to roll partly on
the left side
 Place the Bell of the
stethoscope lightly on the
apical impulse
 Brings out the easily missed
mitral stenosis murmurs or
the soft S3 or S4

50.  First step is to identify S1 & S2
 Start at the base and work your way down
with the diaphragm, then reverse and work
your way up using the bell listening at all the
valve auscultatory areas (see next slide)
 Use “inching” technique- moving the
stethoscope a few cm at a time

51.  Aortic
 2nd ICS RSB (intercostal space right sternal border)
 Pulmonic
 2nd ICS LSB
 Tricuspid
 RV area
 4th ICS left of sternum
 Mitral
 LV area
 Apex
 5th ICS midclavicular line
 Erb’s Point
 3rd ICS at LSB
E

54.  Marks the onset of systole
 Best heard in the mitral area or apex
 High pitched and of longer duration
than S2
 Marks the end of systole
 Best heard in the aortic area or base
 S2 is high-pitched and of shorter
duration than S1
 S1  S2

55.  Marks the onset of systole
 It is the closure of the MV and TV valves
(pathology exists if they are heard
separately)
 Best heard in the mitral area or apex
 High pitched and of longer duration than S2


56.  Marks the end of systole
 Best heard in the aortic area or base
 S2 is high-pitched and of shorter duration
than S1

57.  Once normal heart sounds have been
identified, work on identifying adventitious
sounds:
◦ S3 , S4 (diastolic filling sounds)
◦ Murmurs
◦ Rubs

58.  Classic sign of heart failure (Usually associated with
crackles in the lungs)
 AKA “ventricular gallop”
 Ventricle doesn’t completely empty, new blood
creates a shudder
 Best heard with the bell, at mitral area when the
patient is lying on left side
 An S3 is one of the first clinical signs in cardiac
decompensation such as HF, cor pulmonale, MR,
AR

59. Sounds like
 Ken-tuc-ky
❥“Ken” = S1
❥“tuc” = S2
❥“ky” = S3
or
 Sloshing-in

60.  Reflects the sound of blood from the LA trying to
enter a stiff, non-compliant LV during atrial
contraction
 Signals Diastolic Dysfunction
 Associated with the elderly, HTN, AS, HCM,
history of MI (dead tissue is stiff)
 AKA “atrial gallop”
 Heard best over the apex, using the bell of the
stethoscope.
 Positioned supine or left side-lying

61. Sounds like
 Ten-nes-see
"Ten“ = S4
 "nes" = S1
 "see“ = S2
or
 a-stiff-wall

62.  Increased blood across a normal valve
(exercise, pregnancy, anemia)
 Flow across a partial obstruction (stenosis or
hypertension)
 Flow across an irregularity without
obstruction (bicuspid aortic valve, leaflet
thickening with age)
 Flow into a dilated vessel (aortic root
dilatation)
 Backward flow across an incompetent valve
or through a VSD

63.  Timing
◦ Systolic murmur or Diastolic murmur depending on timing
(also pansystolic vs midsystolic)
 Pitch
◦ High, medium or low
 Intensity (grading) *does not necessarily correlate with
severity of disease
◦ Softer versus loud (see grading scale)
 Sound pattern
◦ Blowing, harsh, musical
 Location
◦ Loudest over certain areas
 Radiation
◦ To neck or axillae

64.  Does the murmur fall between S1 & S2 = Systolic Murmur
sound like "lush-dub"
 Does the murmur fall between S2 & S1 = Diastolic Murmur
sound like "lub-dush"
 Palpate the carotid pulse to help discern the timing
or
 Observe the cardiac rhythm

65. Grade Description
I Barely audible murmur
II Audible but quiet and soft
III Moderately loud without a thrust
or thrill
IV Loud with a thrill
V Very loud with a thrust or thrill
VI Loud enough to be heard before
stethoscope comes in contact
with chest

66.  “High pitched harsh 2/6 holosytolic murmur
best heard at the apex radiating to the axilla”
 “S3 present at apex”

68.  Have the patient sit up lean forward and exhale
 Listen with diaphragm over 3 ICS on left chest
 Has a scratchy, rubbing quality
How do you differentiate between a pleural rub and a
pericardial rub?

69.  https://www.youtube.com/watch?v=J1R8Oxg
qhfk

70.  Listen over Carotid
Arteries for bruit =
noise
 Ask patient to hold
breath
 Bruit MAY be heard- if
totally blocked will not
be
 Not usually equal on
both sides
 Bruit suggest
underlying
atherosclerosis disease

72. Check pressure in both arms upon admission
Difference of up to 10 mm Hg normal
Take BP on highest side and this is the pressure
treated
> 10 mm Hg may suspect:
 Peripheral vascular disease
 Dissection of the aorta
 Subclavian stenosis
 Some congenital defects
 Acquired arterial conditions

73. Target
General Population <140/90
Patient with diabetes <130/80
Patients with CKD, CAD 120-130 SBP

74.  Bruits are areas of turbulent blood flow and
are best heard with the bell of the
stethoscope
 Place the stethoscope over the pulse and do
not push down on the stethoscope
 For patients with large abdominal aprons
and increased adipose tissue in the groin
area it is best to use the diaphragm of the
stethoscope

77.  Finger tips are best suited for palpation of pulses
 The back of our hands are best for assessing
temperature
 The palm of our hand is best suited for assessing
thrills!!

78.  Apical PMI
 Carotid
 Radial
 Femoral
 Brachial
 Radial & Ulnar
 Posterior
Tibialis
 Dorsalis Pedis

79. •Assess quality
•Regular/Irregular
•Grading:
0 = absent
2+ = normal
3+ = bounding
 Absent
 Weak
 Normal
 Bounding

80.  Compare left to right
 Palpate the carotid (not simultaneously),
brachial, radial, ulnar, femoral,
popltieal, posterior tibial and dorsalis
pedis
 Palpate the radial and the femoral
simultaneously, femoral should be
stronger. If not then there may be some
degree of PVD

81.  Palpate for LV PMI
 Sitting/standing +/- left lateral decubitus
 Apex of the heart (5th ICS mid-clavicular line)
 May be the size of a quarter 1-2.5 cm
 If >2.5 cm may mean enlargement
 Note heaves or thrills (purring)
 Volume overload: displacement of the to the left,
downward
 Pressure overload: more forceful tapping, sustained

82.  Heaves: sustained impulses that lift your
fingers, usually due to enlarged right or left
ventricle/atrium or ventricular aneurysm
 Thrills: buzzing or vibratory sensation caused
by underlying turbulent flow. If present ,
listen in the same are for a murmur.

83. Allen’s test-Assesses collateral flow
If negative, check sat/waveform

84. DuManoir, C. (2016).Cardiac Assessment. PowerPoint
Presentation.
Hughes-Myers, C. (2009) Review of Anatomy and Physiology of
the Heart. Powerpoint presentation.
Lilly, L. (2016). Pathophysiology of Heart Disease (6th Ed.).
Philadelphia, PA: Wolters Kluwer.
Mclaughlin, M (2014). Cardiovascular Care Made incredibly easy
(3rd Ed.) Philadelphia, PA: Wolters Kluwer.
Morris, S (2016). Cardiac Assessment for Nurses. PowerPoint
Presentation.