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
- 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
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 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.
Blood pressure is a direct measure of the force exerted by the circulating blood on the walls of the blood vessels (the arteries). It is composed of two numbers – a top and a bottom number.
The blood pressure number on top is the systolic pressure, which is the pressure when the heart is beating. The blood pressure number on the bottom is the diastolic pressure, which is the pressure between beats, when the heart is at rest. These are measured in mm of mercury (mmHg… i.e. 120/80 mmHg).
The blood pressure helps blood continue to flow throughout your body – if the pressure was 0, then your blood would not be circulating!
When one or both of the blood pressure numbers are high, this can be from acute or chronic causes often related directly to the heart (i.e. hypertensive heart disease, fluid overload, etc). Over time, high blood pressure leads to stiff vessels and increased risk of heart attacks and strokes, and other issues.
When the blood pressure is low, this often means the patient has low blood volume, heart failure with cardiogenic shock, vasodilation, or caused by medications or other conditions.
Normal systolic blood pressure is anything less than 120 mmHg. If the systolic blood pressure is above 140 mmHg, this is considered high blood pressure or hypertension and in need of treatment.
Normal diastolic blood pressure is anything less than 80 mmHg. If the diastolic blood pressure is above 90 mmHg, this is considered hypertension and in need of treatment as well.
Elevated blood pressure is often asymptomatic, but acute and significant rises in blood pressure can cause symptoms of chest pain and chest pressure, shortness of breath, and more!
The heart beat or pulse is the amount of times your heart beats in 1 minute. This provides immediate insight into a patient’s heart function, as well as other conditions going on.
Normal heart rate in adults is 60-100 bpm.
Many conditions can cause high heart rate (tachycardia), including dehydration, shock, arrhythmias, fevers, stress, exercise, chest pain, etc.
Low heart rates are sometimes normal, especially if sleeping or in athletes. However, often this is from a cardiac arrhythmia or heart block if it is significantly low, or caused by a medication.
The regularity of the pulse or heart rate is also important, as this can clue you into arrhythmias which are often irregular.
Pulse oximetry measures oxygen saturation of the blood, which is an indirect marker of respiratory AND circulatory efficiency (your heart and your lungs).
Normal SPo2 ranges from 94-100%, and low levels often are related to acute respiratory or cardiovascular conditions.
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:
- 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
So what heart sounds are you listening for? There are normal ones, and then plenty of abnormal ones as well.
S1 and S2
S1 and S2 are the normal expected heart sounds. These are the “lub” (S1) and the “Dub” (S2) with every heartbeat.
S1 indicates the closure of the mitral and tricuspid valves, and mark the beginning of systole (the heart beating).
S2 indicates the closure of the semilunar valves – the aortic and pulmonic valves, indicating the end of systole and the beginning of diastole.
S3 and S4
S3 and S4 are extra heart sounds that typically are not heard in a healthy heart. However, they can sometimes be heard in kids and adults under the age of 40 and be considered “normal”. A pathologic S3 can be associated with heart failure or even elevated blood pressure, and S4 can be associated with stiffness of the ventricle.
Murmurs are sounds produced by turbulent blood flow through the heart valves or nearby structures. These are characterized by their timing, intensity, pitch, and quality. Each valvular issue (i.e. aortic stenosis) have a specific murmur sound associated with them, as well as location that is loudest.
Benign murmurs can be normal in young growing hearts, and these are termed physiologic murmurs.
Valvular issues can be caused from pressure issues, as well as lead to pressure issues within the heart. This can lead to heart failure, arrhythmias, or other severe complications.
Aortic stenosis is the most common valvular issue, and commonly occurs over time (so is fairly common in elderly patients with less-than-ideal hearts with some cardiac disease).
Valvular issues can also lead to atrial fibrillation or other arrhythmias as well.
Pericardial friction rubs may be heard in conditions such as pericarditis. These are high-pitched scratchy sounds, best heard with the diaphragm of the stethoscope.
Auscultating the lungs
Don’t forget the lungs can also clue us into the function of the hearT! Crackles heard in the lungs is also a great indicator of the heart failure and fluid volume overload, flash pulmonary edema, etc.
Read all about Rapid Sequence Intubation here!
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
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.
Absent pulse in extremity?
If you ever cannot detect a pulse in a patient’s extremity, this is a major deal and you should notify the provider team immediately. This is usually in the feet and and from patients who have peripheral arterial disease and poor circulation. There may be color changes as well and decreased capillary refill.
To be sure, it is best to check the pulses with a doppler to see if you can hear the pulse. This is also what the provider team will likely want you to do anyway, so its a good idea to just do it in the first place to make sure.
Be sure to check both the dorsalis pedis pulse and the posterior tibial pulse, and do a complete evaluation of the extremity (Circulation, Motor control, and Sensation).
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.
Kussmaul’s Sign: An increase in JVP on inspiration, suggestive of constrictive pericarditis or severe right-sided heart failure.
Hepatojugular Reflux: An increased in JVP with manual pressure placed over the liver, suggesting heart failure and fluid overload.
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.
12-Lead ECG Evaluation
A 12-lead ECG is the gold standard of electrocardiography. This gives a comprehensive view of the heart’s electrical activity from multiple different angles.
This is most important in ruling out any active cardiac ischemia or infarction going on (a heart attack or lack of blood flow to the heart). It is also important in evaluating cardiac arrhythmias like atrial fibrillation, ventricular tachycardia, and more!
Findings can also give insight into the size of the heart, previous heart attacks, cardiac ectopy, and more!
Continuous Cardiac Monitoring
Continuous cardiac monitoring (aka telemetry) is often performed on patients in the ER who have potential cardiac or respiratory complaints such as chest pain, shortness of breath, weakness, dizziness, etc.
Pretty much ALL ESI level 1 and 2s should be on cardiac monitors, and some level 3s. In the hospital, this is often ordered for patients going to a telemetry unit, progressive care, or other higher levels of care.
This consists of a cardiac monitor (whether bedside or portable) hooked up to the patient’s chest with 3-5 wires on their chest to detect 3-5 different views of the cardiac rhythm. Usually lead II is monitored for cardiac arrhythmias and heart rate.
Evaluating the rate and rhythm is common and often needed to be done at least once per shift, more in critical patients or with changes.
To help you understand how to evaluate cardiac rhythms – check out “How to Read an ECG Rhythm Strip“.
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.