Cardiac Assessment
diseases and bleeding disorders
By: Bryan Mae H. Degorio, RN, MAN
A. Risk Factor Analysis for Cardiovascular
Diseases
 Gender and Age
 Family history of hypertension
 Family history of heart attack
 Family history of diabetes mellitus
 Cholesterol level
 Serum triglycerides
 Frequency of recreational activity
 Frequency of occupational exercise
 Cigarette smoking
 Stress at home and at work
 Behavioral pattern
 Use of oral contraceptives
 Air pollution
 Sleep Pattern
B. Biographic and Demographic Data
- Name, age, sex, place of birth, race,
marital status, occupation and ethnic
group
• Race- heart disease has twice
mortality to Native Americans
- Black die twice in stroke
compared to white
• Age- coronary artery disease are
more fatal to those who have
developed it young
- cardiovascular disease are
common among the elderly
-NO such this as congenital
RHD
C. Past Health History
1. Childhood Illnesses- previous
streptococcal infection and corrected
congenital heart diseases
2. Immunization- cardiovascular disorders
needs revaccination of influenza every 6-
10 years
3. Major Illnesses and Hospitalization- pt.
with DM, obstructive lung diseases,
kidney problem, anemia, HPN, stroke,
gout, thrombophlebitis, collagen
-surgical procedures, OB history
(complications of prev. pregnancy
due to CVD), outpatient interventions
and Dx procedures
4. Medication- use of herbs, OTC and
recreation drug
-note for the route, dosage and
frequency of use
5. Allergies- foods, drugs and note for
manifestation during acute attack
D. Family Health History
• Provide insight for genetic,
environmental and lifestyle
related diseases that contribute
to the occurrence of cardiac
problem
• Note for history of DM, HPN,
stroke and kidney disorders in
the family
• Modifiable: stress, weight,
cholesterol level, smoking and
abuse
• Non-modifiable: heredity, age,
sex and race
E. Psychosocial History
1. Occupation- occupation stress, workload,
job orientation (hard labor or sedentary
work), occupational hazard, jobs that
might not be compatible with existing
CVD
2. Geographical Location- death caused by
cardiac event where they live (ex: US and
Philippines)
3. Environment
• Home hazard such as area for
repair, presence of stairs, and
light condition
• Transportation (mode and access
to health care facility)
• Neighborhood – noise pollution
• Access to facility- hospital,
church, grocery and pharmacy
• Nurturing environment-conducive
place for recovery
4. Exercise
• Type of exercise (isotonic,
isometric, isokinetic, passive,
aerobic and anaerobic)
 • Aerobic exercises – lower the
chance of developing coronary
artery disease
• Note: anaerobic exercises-
increase of 50- 100% 0f the
baseline HR at least 30 min. 3-5
times a week
• Consult physician if to be
performed by 40 y/o and above
• Effects of sedentary lifestyle-
increases the lethality of MI
5. Nutrition
• Assess for caloric intake, Na,
cholesterol and saturated fat
including caffeine intake
• Assess for economic and cultural
status before recommending for
dietary changes
• Foods such as fruits, vegetables,
low fat dairy products and
saturated fat reduces the BP
significantly
6. Habits
• Smoking- nicotine and tar, assess
for # of packs/day and the how
long the client has been smoking
-it increases coronary artery
disease and worsen hypertension
• Caffeine
-↑the risk
atherosclerosis
- ↑ HR and BP thus
precipitating angina,
palpitation and dysrhythmias
- limit caffeine intake to 8 oz
of coffee/day to those with
known diseases
• Alcoholism- an intake of 100 mg
of alcohol (3 beer) may increase
heart rate and BP
-ask for daily and weekly
consumption of alcohol
- Note: client may lie about the
type and amount of alcohol
consumed (denial)
Physical Assessment
- Cardiac Physical assessment includes the
following:
• General appearance
• PB, pulses, jugular veins
• Percuss, palpate and auscultate
the heart
• Evaluation of edema
- How it is done?
• Position client in supine position,
stand at client’s side and elevate
bed
• From head to toe
• Prepare the equipment-
stethoscope, penlight, ruler and
application stick
A. General Appearance
- Restlessness, can the client lie or sit
upright, signs of pain, cyanosis, pallor
and presence of dyspnea
B. Head, Neck, Nails and Skin
• Head- eyes, earlobe, lips and buccal
mucosa
a. Note for:
1. Arcus senilis – a light gray
ring around the iris (may
indicate cholesterol deposit)
2. Xanthelasma – yellow raised
plaqued around the eyelids
( duse to lipid deposits)
• Skin- assess foe central and
peripheral cyanosis
a. Central cyanosis- assess the skin,
buccal mucosa and nasal mucosa
 May indicate severe
heart and lung
diseases
b. Peripheral cyanosis- check the
nailbed, earlobe and lips
 Indicates peripheral
vasocionstriction (ex:
reynauds disease)
• Nails
a. Capillary refill
 Or blunch test
 Check capillary refill
before giving pulse
oximeter
 Normal- 2 seconds
b. Clubbing of finger
  Normal- 160⁰
 180⁰ ↑- associated with
prolong oxygen
deprivation
 Can be due to COPD or
chronic anemia
c. Skin Turgor
 Can be done by lifting a
fold of skin over the
sternum or lower arm or
abdomen then release
 N⁰- goes back
immediately (2-3 seconds
 Late- indicate
dehydration, malnutrition
and advancing age
d. Temperature
 Warm- associated with
venous disorders and
thyrotoxicosis
 Cold- arterial occlusive
disorders and
hypothyroidism
• Edema
a. Note for the location of edema:
 Lower extremities-
mobile patients
 Buttocks or scapular –
bed ridden patients
 Peripheral edema- RSCHF
 Pulmonary edema
(dyspnea and crackles)-
LSCHF
C. Blood Pressure
- Measure BP initially in both arm- identify
presence of coarctation, aneurysm,
occlusive disorders and errors in reading
1. Postural Blood Pressure
 Done when extracellular volume
depletion and decrease vascular
tone is suspected
 Position client in supine, sitting
and standing
 Note the position while taking
the blood pressure
 Abnormal finding: A drop in blood
pressure of more than 10-15 mm
Hg systolic and more than 10 mm
Hg for diastolic pressure
indicates postural hypotension
 Hypotension is usually
accompanied by 10-20% increase
in the heart rate
2. Paradoxical Blood Pressure (Pulsus
Paradoxus)
 An abnormal ↓of more than 10
mm Hg of the systolic blood
pressure during expiration
 Associated with : pericardial
tamponade, constrictive
pericarditis and pulmonary
hypertension
D. Pulses
- Note bilateral pulse
- Assess for pulse deficit by counting
apical pulse simultaneously with radial
pulse
- Note for weakness, thready and if it is
bounding
E. Neck
1. Neck Veins
 Neck vein distention can be used
to estimate CVP (Central Venous
Pressure)
 The amount of distention reflects
pressure and volume changes in
the Right Side of the Heart
a. External jugular Vein- easy to
detect but can be altered by
little changes in position
b. Internal Jugular Vein- most
reliable indication of CVP
 How it is done:
1. Elevate the head by 15-30⁰
2. 45-90⁰ for those with
increase right atrial pressure
3. Internal jugular vein is just
located or lies deep in the
sternocleidomastoid
4. Place the ruler on the sternal
angle
5. Measure the pulsation
6. N⁰- < 3-4 cm and an ↑
indicates RSCHF and
pericardiac tamponade
 7. Contralateral distention  Pulmonic area- second
indicates onbstructions intercostals space Left of the
sternum
2. Carotid Artery
 Erb’s Point- 3rd intercostals
 Indicates adequacy of stroke
space Left of the sternum
volume and patency of the
arteries
 Tricuspid area- 5th intercostal
 Palpate one side at a time- space on the left side of the
simultaneous palpation sternum
stimulates carotid sinuses
causing bradycardia and sinus  Mitral area- 5th intercostals
arrest space MCL left side

 Note for Bruits- a blowing sound • Notes:

heard using the diaphragm of the
stethoscope  Low pitch- Bell of the
stethoscope
 It indicates narrowing of carotid
artery  High pitch- diaphragm

F. Chest • Normal Heart Sounds:

1. Pericardium
 First Heart Sound (S₁)
• Note for size, symmetry and evidence
a. Closure of the AV valves
of any pulsation – record its location
during ventricular
in relation to MCL and IS
contraction

• PMI (Point of Maximal Impulse)- 5th b. Heard best at mitral and

Intercostal Space MCL tricuspid region

 It is associated to left c. It is equivalent to carotid

ventricular contraction artery pulsation or
upstroke of R wave in
 Prominent in thin and QRS complex
obscure in fat of have large
breast d. Its intensity varies
according to certain
 2 fingerbreadths below the pathologic condition such
nipple or 2 cm as stenosed AV valves

 If deviated- can be due to

Right or left Sided
Cardiomegaly
• Note for presence of heaves or lifts
 These are visible pulsation
associated to pulmonary
hypertension
• Thrills
 These are rushing vibration
palpated in 5 cardiac
auscultatory region that may
indicate murmur
 Second Heart Sound (S2)
a. The closure of the
semilunar valves during
ventricular relaxation
b. It marks the end
ventricular systole and
onset of diastole
(ventricular filling)
c. Best heard in aortic and
pulmonic area using the
diaphragm
 Physiologic Splitting of S₂

 Represent turbulent blood

a. Normal
flow through the heart
especially across an
b. Due to delayed closure of
abnormal heart valves
the pulmonic valves

2. Heart Sounds
c. Best heard during
inspiration
• Cardiac Auscultatory Site

- causes negative pressure in the thoracic

 Aortic- second intercostals cavity→ pulling of blood on the right
space Right of the sternum
 ventricles→ delayed emptying→ delayed
closure of the pulmonic valves as heard
as split second heard sound
• Abnormal Heart Sounds
 Pathologic Splitting
a. Wide splitting of S₂
b. Heard best during
inspiration and expiration
with an increase during
inspiration
c. Associated with bundle
branch block→ delayed
ventricular impulse
transmission→ delayed
depolarization→ late
closure of pulmonic
valves
d. Associated with atrial
septal defects
e. Fixed Splitting- due to
prolong emptying of the
right ventricle
f. Paradoxical Splitting- due
to stenosed aortic valve
which is heard best
during expiration
 Gallop
a. Diastolic filling sounds
(S₃ and S₄)
b. Due to sudden changes
of inflow volume causing
vibration of the valves
and the ventricular
supporting structures
producing low pitch
sound either early (S₃) or
late (S₄) as diastole
S₃
a. during passive and rapid filling of the
ventricles
b. Early gallop that is heard during early
diastole
c. It follow immediately after S₂ and is dull
and low pitch sound
d. N⁰ in children and young adult
e. Older than 30- it is considered a
characteristics of Left ventricular
dysfunction such as CHF, MI and Valvular
incompetence
S₄
a. Occurs in the later stage of diastole
during atrial contraction and active filling
of the ventricles
b. Heard immediately before S₁ and is
referred as atrial gallop
c. It is associated with ventricular
hypertrophy, ischemia and fibrosis
d. Never heard in the absence of atrial
contraction
• Quadruple Rhythm
 Is noted when both S₃ and S₄
are audible
 Client with this heart sound
often have tachycardia which
causes the diastolic filling
sound to fuse forming
summation gallop that maybe
louder than S₁ and S₂
 It resembles the sound of a
galloping horse
• Clicks- are extracardiac sound
that can be heard anytime
during the cardiac cycle in client
with aortic stenosis, valve
prolapsed and prosthetic valves
• Pericardial Friction Rub
 Is produced by inflammation
of the pericardial sac
 It is describe as a scratchy,
grating, rasping and much
like “squeaky leather” sound
 Heard through the
respiratory cycle not like
pleural friction rub that occur
during inspiration
 The roughened parietal and
visceral layers of the
pericardium against each
other during cardiac motion
• Murmur
 Is heard as consequence of
the turbulent blood flow
through the heart and blood
vessels
 It is caused by:
a. ↑ rate or velocity of the
blood flow
b. Abnormal forward and
backward flow in the
 stenosed or incompetent f. Grade VI- very loud,
valves heard even without
stethoscope
c. Dilated chamber
3. Lungs
d. Flow through abnormal
passage between heart • Tahcypnea
chambers (VSD, ASD and
TOF) • Crackles

 Systolic murmur  Adventitious sound heard in

a. Also called “benign
murmur”
b. Often caused by vigorous
contraction of the
myocardium or strong
blood flow
c. Common in children and
adults younger than 50
and pregnant women
 Diaslotic Murmur
a fluid filled lungs
 Common in LSCHF and heard
well in the base of the lungs
• Blood Tinged Sputum
 May indicate acute pulmonary
edema accompanied by crackles
• Cheyne-Stoke Respiration
 Deep breathing with period of
apnea

a. A pathologic
 Common in patients with heart
condition and is produced
failure and anemia
by the mitral and
tricuspid valve stenosis 4. Abdomen
or aortic and pulmonic
insufficiency
• Ascitis

 Note the characteristics:

 due to fluid accumulation in the
peritoneal cavity
a. Loudness
 can be due to chronic right
b. Location
ventricular failure
c. Pitch- high or low,
• Bowel Sounds
musical, harsh, blowing
or buzzing
 ↓ indicate potassium depletion
d. Place and duration
 Loud bruits above the umbilicus
e. Quality- crescendo, may indicate aortic aneurysm or
decrescendo or plateau stenosis

f. Radiation- sounds radiate 5. Do the Following:

to other part of the body
(aortic radiates to carotid
artery and mitral murmur
radiates to axilla)
g. Variation- changes occur
with movement
 Grade the Loudness
a. Grade I- faint
b. Grade II- Faint heard
immediately
• Allen’s Test
 Use to assess blood supply to the
upper extremities particularly the
hand
 As the pt have close fist (tight)→
compress the ulnar and radial
artery→ have the client open his
hands (n⁰- pale and mottled-
released the radial pulse- n⁰
hands regain color in about 6
seconds)

c. Grade III- Moderately

loud

d. Grade IV- Loud

e. Grade V- Very loud, heard

only with stethoscope
• Homan’s sign

 Pain in the calfs

 Done by compressing the

gastrocnemius or quickly
dorsiflexion

 Note for pain