Nursing Assessment of the Cardiovascular System

Nursing Assessment of the Cardiovascular System
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  • 0:00 Understanding CV Assessments
  • 1:25 Patient Interview
  • 2:14 Heart Sounds
  • 3:01 Circulation
  • 4:04 Fluid Volume
  • 5:15 Lesson Summary
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Lesson Transcript
Instructor: Julie Eiler
This lesson reviews the sections of a cardiovascular nursing assessment, examines subjective and objective data, and explores the relationship between assessment and the patient condition. Learn about the skills needed to perform the assessment.

Understanding CV Assessments

Ever wonder why people refer to their heart as the 'old ticker'? The rhythmic tick tock, tick tock of a clock sounds a bit like that heart that beats in our chest for the duration of our life. The heart works nonstop pumping blood and oxygen to the body and is part of the cardiovascular (CV) system. This process is essential to every organ in the body and to human life itself. It makes sense then that a thorough cardiovascular assessment includes far more than just listening to the heart beat.

A registered nurse is responsible for thoroughly assessing a patient's physical condition and using that information to guide care. Subjective data is the patient's report including symptoms and complaints. Objective data is the physical findings that the nurse can see, feel, or hear.

It's often best to begin with collecting subjective data, because the patient's responses can prompt the focus of the objective assessment. For example, asking about pain during palpation. Both subjective and objective findings, as well as data like vital signs, cardiac rhythms, and lab results are important to the overall clinical picture of the patient.

To help, it's helpful to first review the patient history to learn about current medications and any chronic diseases or recent hospitalizations, which can help direct the assessment.

Patient Interview

Issues with the heart present as various symptoms in the patient, but a few things should always be considered with a cardiovascular assessment. First, ask the patient about current or recent chest pain. Pain in the chest, or even the jaw or arm can be a manifestation of ischemia, which is lack of blood flow to tissue caused by a blockage. Pain in these areas can also be symptoms of other problems, so it's important to compare symptoms to other clinical findings.

Next, ask the patient about dizziness, palpitations, sweating, or shortness of breath. These may be symptoms of an irregular heart rhythm or heart failure. Ask the patient about pain, numbness, and tingling to extremities (usually to the calves and feet), as this may reflect circulation issues. Report and document any abnormal symptoms.

Heart Sounds

The cardiovascular physical assessment begins with the heart itself. Listening to heart sounds, usually with a stethoscope, is referred to as auscultation. Auscultation can tell you if the rhythm sounds regular or irregular, how fast the heart is beating, and whether there are flow abnormalities, like murmurs. Murmurs refer to extraneous sounds of abnormal blood flow in the main vessels or through inadequate valves and can take a trained ear to detect and differentiate. Basic heart sound auscultation is done in four spots on the chest: aortic, pulmonic, tricuspid, and mitral. As you listen in each area, think about the anatomy of the heart; each auscultation point is over a valve and allows for assessing a different part of the heart's function.

Circulation

The heart sends blood to the farthest points of part of the body. Assessing perfusion, or blood circulation, is done in a few ways. Palpating pulses can assess whether efficient blood flow is making its way to the extremities, which are your arms and legs. Radial pulses in the wrists and dorsalis pedis pulses on the feet represent the most distal, or farthest from the heart, pulses. Compare the rhythm and rate of these pulses with heart sounds to determine if each beat is pumping all the way to the distal extremities. The strength of the pulse is described as absent, weak, strong, or bounding (very strong) on a scale from 0 to 4.

Circulation can also be assessed by the color of the extremities. Well-perfused tissue, like feet and toes, should be pink, feel warm, and have brisk capillary refill. Capillary refill is tested by pressing or pinching the tissue and then releasing. The tissue should turn white and then quickly return to a pink color as the blood rushes back into the capillaries.

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