The advanced cardiovascular assessment is important for every nurse to know, as the heart and cardiovascular system is so important in the body.

Proper evaluation of the heart involves auscultation for normal and abnormal heart sounds, palpating the PMI and peripheral pulses, checking vital signs, evaluating for Jugular Venous Distention, and evaluating the cardiac rhythm. 

Why is the Cardiovascular Assessment Important?

This may seem like an obvious question, but it is important to address regardless. The cardiovascular assessment is so important in nursing because the heart is so important in the body. The heart, brain, and lungs are the most important organs in your body, and are essential to every minute you are alive.

Additionally, heart disease is the leading cause of mortality globally. By detecting heart disease and cardiovascular complications early, we can literally save patients lives.

There are so many complaints and diseases that bring patients into the hospital that are related to the heart, including:

• Chest Pain
• Heart Attacks (myocardial infarction)
• Hypertensive episodes
• Heart Failure
• Myocarditis
• Aortic Dissections
• and more!

Patients with cardiac risk factors become even more important to do a thorough cardiac examination on them.

Utilizing many of these standard and advanced cardiovascular assessment techniques can give us a great insight into the function of a patient’s heart and overall health. This is important even when our patients are healthy, but essential when our patients are sick and in the hospital and/or ER settings.

When should a Cardiovascular assessment be done?

The heart assessment should be done pretty much with EVERY single focused and comprehensive physical examination. However – there are times when the heart will not be evaluated at all and assumed to be healthy (a walkie-talkie patient in an outpatient setting).

Because the heart is so important and can lead to so many different symptoms, it generally is always at least auscultated to by the doctor and nurses, especially in the hospital setting. Blood pressure is almost always checked during every appointment or evaluation, and usually heart rate and pulse ox as well in the ER or inpatient settings.

The advanced portion of the cardiovascular assessment usually includes things like finding the PMI heart location, JVD assessment, murmur evaluation, and 12-lead ECG /telemetry evaluation. Some of this responsibility lies on the provider, but it is important for nurses to know how to assess and evaluate these as well.

The Advanced Cardiovascular Assessment

The history

While this article focuses on the physical examination of the cardiac assessment, never forget just how important the patient history is. The history will guide the physical examination and will help lead to a proper diagnosis and appropriate treatment.

The nurse and provider team should be collecting information about:

• Personal history of coronary artery disease or other heart disease , diabetes, or other associated conditions
• Family history of coronary artery disease /heart disease
• Current symptoms and related information (PQRST)
• Cardiac medications they may be taking
• Social habits (alcohol, smoking, etc)

Vital Signs

Vital signs like blood pressure and heart rate provide a snapshot patient’s overall stability – if their vital signs are bad, then the patient is unstable and likely needs immediate intervention.

Many of the vital signs evaluate how well the heart is functioning, including the blood pressure, the heart rate, and the pulse ox. These are essential to evaluate when patients have chest pain, shortness of breath, or other similar complaints.

Cardiac Auscultation

Auscultation involves listening with a stethoscope – this is super important for the cardiac and respiratory assessments, especially if the patient is complaining of chest pain or shortness of breath, or similar complaint.

When listening to the heart, you should be listening for:

• Regularity
• Normal/expected heart sounds
• any presence of abnormal heart sounds

If the heart is irregular, this can mean an arrhythmia such as atrial fibrillation.

How to auscultate the heart

Listening to heart sounds involves placing your stethoscope at 4-5 different areas of the heart and listening for the normal and any abnormal heart sounds at each location.

Why do we use each location? Essentially you are listening at the sites where you can hear each heart valve the best. When heart valves are damaged or diseased, they often lead to murmurs or abnormal heart sounds, caused by abnormal blood flow through these doorways in the heart.

The different heart areas include:

• Aortic: Right 2nd intercostal space at the sternal border
• Pulmonic: Left 2nd intercostal space at the sternal border
• Erb’s point: Essentially right in the middle, located at 3rd intercostal space left of the sternum
• Tricuspid: Left lower sternal border
• Mitral (apex): left fifth intercostal space at the midclavicular line

Heart sounds

So what heart sounds are you listening for? There are normal ones, and then plenty of abnormal ones as well.

PMI heart

The PMI stands for Point of Maximal Impulse. This is where the heart beat is most powerfully palpated on the chest wall.

To assess the PMI, the patient should be placed supine or in a left lateral decubitus position. Nurses should use the pads of their fingers to palpate the chest wall and feel for the strongest pulse.

The PMI should be located on the fifth intercostal space at the midclavicular line (same as the mitral area where you listen).

When evaluating, it is best to start from the right sternal border and move laterally toward the apex of the heart. Once found, the following aspects should be evaluated:

• Location: A displaced PMI (not in the expected location) can suggest an enlarged heart if laterally displaced, or if inferiorly displaced, it can indicate a diaphragmatic hernia or abdominal mass.
• Size: The PMI is typically only felt within a 2.5cm diameter. If enlarged, this can indicate left ventricular hypertrophy
• Amplitude: If the force is stronger or weaker than expected (hyperdynamic), this can indicate Inotropy of the heart (how strong the heart is beating)
• Duration: Sustained impulse that lasts more than 2/3 of the systole suggests left ventricular hypertrophy

Peripheral Pulses

Palpating the peripheral pulses provides insight to the body’s systemic arterial circulation – basically how well the heart is circulating the blood throughout the body.

The presence, quality, and regularity of the peripheral pulses can provide important clues about the cardiac output and peripheral vascular health.

Palpating the peripheral pulses

Peripheral pulses should be palpated in the upper and lower extremities. Not EVERY single peripheral pulse needs checked, although this would be the most thorough.

Peripheral pulse options include:

• Radial pulse
• Brachial pulse
• Carotid pulse
• Femoral pulse
• Popliteal pulse
• Dorsalis pedis pulse
• Posterior Tibial pulse

When documenting the assessment of peripheral pulses like the radial pulse, nurses use a grading scale to describe the amplitude or strength of the pulse:

• 0: Absent pulse, no detectable pulse under normal conditions
• +1: Thready or weak pulse, difficult to palpate, may fade in and out
• +2: Normal pulse, easily palpable, not easily obliterated
• +3: Bounding pulse

Weak or absent pulses may suggest arterial occlusions or significant hypotension (or even ventricular arrhythmia or asystole).

Bounding pulses may occur with fever, anemia, hyperthyroidism, states of stress, etc.

Asymmetrical pulses may reveal peripheral vascular disease or aortic dissection.

Bruits & Thrills

Bruit is a French word meaning “noise” and indicates turbulent blood flow. Essentially this is like a murmur that is auscultated with the stethoscope over an artery (instead of the heart). This is not normal and can indicate carotid stenosis (or other artery stenosis). Abdominal bruits may indicate renal artery stenosis or abdominal aortic aneurysm.

Thrills are vibrations felt that indicate a severe form of turbulent bloodflow, often due to a valvular heart disease or arterial obstruction.

In an AV fistula, it is normal to have both a bruit and a thrill, and this is a good sign that the fistula is in proper working order!

Jugular Venous Pressure

Jugular Venous pressure (JVP) reflects the pressure in the venous system by visualizing the internal jugular vein. This offers insight into the right atrial pressures and central venous pressures.

Jugular Venous Distention (JVD) can occur when this pressure is elevated, often in conditions such as:

• Fluid overload states
• Right ventricular failure
• Tricuspid valve disease
• Pericardial constriction or tampanode
• Pulmonary hypertension

How to assess Jugular Venous Pressure

JVP is primarily assessed with two different signs: Kussmaul’s sign, and the hepatojugular reflux.

To measure the JVP, place the patient semi-fowlers at a 30-45 degree angle. Have the patient turn their head to the left. Visualize the external jugular vein, but remember that the internal jugular vein is a more accurate reflection of CVP.

The internal jugular vein is observed between the sternal and clavicular heads of the sternocleidomastoid muscle, and you should be able to visualize the pulsations.

Identify the top of the venous pulsations of the external jugular vein, or preferably the internal jugular vein. Use a pen to “draw” or visualize a horizontal line from the top of the pulsations to above the sternal angle.This is the notch where the sternum begins. Now measure how high this horizontal line is above the skin. Then add 5cm because the right atrium is approximately 5cm deep. The total is the patient’s estimated central venous pressure (CVP).

For more information on this technique, check out this article here.

Measurements > 4cm indicate JVD and suggest elevated central venous pressures.

ECG and Telemetry Evaluation

Electrocardiography (ECG) and telemetry monitoring are essential components of a cardiovascular assessment, especially for ER and inpatient settings. If the patient has chest pain, shortness of breath, or some other symptom, this becomes even more important to rule out a myocardial infarction, cardiac ischemia, or cardiac arrhythmia.

Wrapping it up

Nurses play a pivotal role in the early detection and management of cardiac disease and heart complications. The comprehensive techniques outlined – from vital signs to jugular venous pressure evaluation, from auscultation to ECG and telemetry interpretation – equip nurses with the tools necessary to make critical decisions that can alter the course of a patient’s care.

American Heart Association. (2020). 2020 Handbook of Emergency Cardiovascular Care for Healthcare Providers. American Heart Association.

Bickley, L. S., & Szilagyi, P. G. (2017). Chapter 9. In Bates’ Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.

Jarvis, C. (2019). Physical Examination & Health Assessment (8th ed.). Saunders.