cardiovascular disorder

Nursing Managementof Patients withCardiovascular Disorders

Chapter 37 Nursing Assessment of Patients with CardiovascularDisorders 1052

Chapter 38 Nursing Interpretation of theElectrocardiogram 1074

Chapter 39 Diagnostic and Interventional Therapies for Cardiovascular Disorders 1119

Chapter 40 Caring for the Patient with Coronary ArteryDisorders 1158

Chapter 41 Caring for the Patient with Cardiac InflammatoryDisorders 1219

Chapter 42 Caring for the Patient with Heart Failure 1278

Chapter 43 Caring for the Patient with Peripheral VascularDisorders 1323

8UNIT

NURSES NEED in-depth knowledge and skills in order to as-sess the cardiovascular status of their patients rapidly. Althoughthe cardiovascular system is complex, its purpose is simple: todeliver oxygen and nutrients to the tissues and cells of the body.An understanding of cardiovascular anatomy and physiology isessential for cardiovascular assessment. Additionally, it is im-portant to gather data about the patient’s medical history as wellas the presenting symptoms, because they can provide clues tocardiac status. The relationship between the existence of riskfactors and the patient’s susceptibility for disease is an impor-tant concept this chapter presents.

A thorough physical examination, including inspection, pal-pation, and auscultation, helps to define an individual’s abilityto carry out the physiological function of the cardiovascular sys-tem. Nurses should be able to recognize normal assessmentfindings and, more importantly, to identify subtle abnormalitiesor deviations from normal that might indicate worsening of thepatient’s condition. Accuracy in monitoring and reporting ofdata is essential, and nurses have access to a wide variety of non-invasive and invasive technological devices that assist in cardio-vascular monitoring and assessment.

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Nursing Assessmentof Patients withCardiovascular Disorders

CHA

PTER 37

Outcome-Based Learning ObjectivesAfter studying this chapter, the learner will be able to:

1. Compare and contrast the significance of cardiovascular assessment findings.

2. Evaluate the relationship of current health status and the presence of cardiac risk factors.

3. Describe the relationship of clinical manifestations to data obtained from the review of a patient’s social history.

4. Describe the essential components of a cardiovascular physical assessment.

Kristine L’EcuyerWith contributions by:

Kathleen Osborn

Anatomy and Physiology of the Cardiovascular System

An in-depth cardiovascular assessment requires knowledge ofcardiovascular anatomy and physiology, and an ability to inte-grate that knowledge into the current condition of each patient.As seen in Figure 37–1 �, the heart is housed directly behind thecentral section of the thorax referred to as the mediastinum.Two-thirds of the heart lies to the left of the midline. The apexlies just above the diaphragm and the base of the heart lies ap-proximately at the level of the third rib. The exact size of theheart varies among individuals, but on the average it is approx-imately 5 inches long and about 3 inches wide, resembling thesize of a closed fist.

The heart is a four-chambered muscular organ composed oftwo separate pumps, each having one atrium and one ventricle.The upper chambers (atria) of the heart are separated by the in-teratrial septum, and the ventricles are separated by the inter-ventricular septum. The two atria are located at the base or topof the heart, and the lower chambers are located at the bottomor apex of the heart. The upper chambers are thin walled and re-

CHAPTER 37 Nursing Assessment of Patients with Cardiovascular Disorders 1053

FIGURE 37–1 � Diagram of heart in chest.

3rd rib

Angle ofLouis

Suprasternalnotch

Intercostalspace

Diaphragm

1

2

3

4

FIGURE 37–2 � Cross section of heart.

Chordae tendineae

Atrioventricular (AV) valves:

Av

T

S

TricuspidBicuspid (Mitral)

Semilunar (SV) valves:

B(M)

AP

PulmonicAortic

Papillary muscle

ceive blood as it returns to the heart. The right atrium receivesblood from the systemic venous circulation, while the leftatrium receives blood from the pulmonary circulation. Thelower chambers have thicker walls and pump blood out of theheart. The right ventricle pumps blood into the pulmonary cir-culation, while the left ventricle pumps blood into the systemiccirculation. Although each ventricle pumps the same volume ofblood, the left ventricle has a larger, stronger muscle. This in-creased strength is needed because the left ventricle has to pumpblood into the systemic circulation, which has five times greaterpressure than the pulmonic circulation. The heart wall is com-posed of the three layers:

1. The epicardium: the smooth outer serous layer.

2. The myocardium: the middle muscular layer, which is thethickest of the three layers and is responsible for the heart’sability to contract.

3. The endocardium: the inner lining of the heart, which iscomposed of thin connective tissue. This smooth inner sur-face and the valves allow blood to flow more easily through-out the heart.

Cardiac ValvesThere are four valves in the heart (Figure 37–2 �). The purposeof the valves is to ensure that blood travels in only one directionas it passes through the heart. The valve opens to fill a chamberand then closes when the pressure in the chamber builds,thereby allowing blood to continue to flow in one direction. Theatrioventricular (AV) valves are located between the atria andthe ventricles (see Figure 37–2 �). These valves are referred to asthe tricuspid valve and the bicuspid or mitral valve. The tricus-pid valve lies between the right atrium and the right ventricleand is so named because it has three cusps. The mitral or bicus-pid valve has only two cusps and is located between the leftatrium and the left ventricle. The cusps of both the mitral andthe tricuspid extend into the ventricles where they attach to thechordae tendineae. Chordae tendineae are cords of dense con-nective tissue that attach to the papillary muscles (see Figure37–2 �). The chordae tendineae and the papillary muscle work

together to prevent the valve cusps from fluttering back into theatrium and thereby interrupting forward blood flow. The semi-lunar valves are the pulmonic and the aortic valves. Each semi-lunar valve contains moon-shaped cusps (semilunar). Thepulmonic valve is located between the right ventricle and thepulmonary artery. The aortic valve is located between the leftventricle and the trunk of the aorta.

As blood is filling the ventricular chamber, pressure is rising.The ventricular muscle fibers respond to an increase in bloodvolume by stretching to allow more fluid into the chamber(Starling law). As pressure in the ventricles increases, the ven-tricular muscles stretch. When the pressure in the right ventricleis greater than the pressure in the pulmonary system, and like-wise, when the pressure in the left ventricle is greater than thepressure in the aorta, the AV valves (tricuspid and mitral) snaptogether to close as the semilunar valves (pulmonic and aortic)open. The ventricular muscles contract, and blood is ejectedthrough the open pulmonic valve to the pulmonary artery andthe pulmonary circuit, and through the open aortic valve to theaorta and the systemic circulation.

Surrounding the heart is a two-layered sac referred to as thepericardial sac (Figure 37–3 �, p. 1056). The outer layer, calledthe parietal pericardium, is in direct contact with the pleura(lung). This layer consists of a tough, nonelastic, fibrous connec-tive tissue and serves to prevent overdistention of the heart. Thethin, serous inner layer of the pericardium, called the visceralpericardium, lays directly on the epicardium or outer layer ofthe heart. There is a small amount of fluid between the heartwall and the pericardial sac (approximately 10 mL). This fluidacts as a lubricant to prevent friction during contractions.

Cardiac Circulatory SystemThe heart has its own circulatory system allowing for con-stant nourishment of blood to the cardiac muscle. The heart’scirculatory system consists of coronary arteries and veins

1054 UNIT 8 Nursing Management of Patients with Cardiovascular Disorders

FIGURE 37–3 � Layers of heart.

RV

LV

Transverse section of the heart

Endocardium

Lung

LA

RA

RV

LV

Myocardium

Epicardium

Visceral

Serouspericardium:

ParietalCavity ofpericardialsac

FIGURE 37–4 � Coronary arteries.

Right coronaryartery

Left maincoronaryartery

Circumflexcoronaryartery

Left anteriordescendingcoronaryartery

(Figure 37–4 �. The sinuses or openings into the coronary arter-ies lie at the base of the aorta, just above the aortic valve. Asblood leaves the heart with each beat, it travels through the coro-nary sinus to supply the cardiac muscle. The two main arteriesare the right and left coronary arteries. The right coronary arteryand its branches normally supply the right atrium and ventricleand a portion of the posterior wall of the left ventricle. The leftcoronary artery branches into the left anterior descending andthe circumflex arteries, both of which feed the left atrium andthe massive walls of the left ventricle. The left coronary arterycarries 85% of the blood flow to the myocardium. The left ante-rior descending (LAD) artery feeds the anterior wall of the leftventricle and the interventricular septum. The circumflex arteryfeeds the lateral and posterior portions of the left ventricle.

The pulmonary circulation consists of blood flow betweenthe heart and lungs. Blood leaves the right ventricle, enters the

pulmonary artery and lungs, picks up oxygen, and travels tothe left side of the heart. The systemic circulation consists of anetwork of arteries, capillaries, and veins. Blood leaves theheart, travels through these vessels delivering oxygen and nu-trients to the tissues, and then returns to the right side of theheart to pick up more oxygen.

Physiology of the Cardiovascular System

The right atrium is the central point in the body where unoxy-genated blood from the systemic circulation returns. It thentravels through the tricuspid valve to the right ventricle, throughthe pulmonic valve to the pulmonary arteries into the lungs,through the pulmonary alveolar-capillary network into the pul-monary veins, into the left atrium, through the mitral valve intothe left ventricle, and finally out the aortic valve to the systemiccirculation.

Freshly oxygenated blood, traveling through the aortic valve,also enters into the coronary arteries to supply the myocardiumwith oxygen. Normally the myocardium extracts 75% of theavailable oxygen from the coronary arteries. This is more than isextracted from any other tissue in the body; the rest of the bodyextracts about 40%. If oxygen needs are not met from this nearmaximal extraction, then blood flow must be increased. With ahealthy heart, blood flow is increased in two ways. First, the ar-teries are able to dilate, thereby increasing their capacity, andsecond, the myocardial muscle increases the force of the con-traction, pumping more blood into the arteries. These twomechanisms result in an increase in the cardiac output andblood flow to the myocardium.

Cardiac CycleThe pumping action of the heart consists of contraction andrelaxation of the myocardial layer of the heart wall. Each con-traction and relaxation is one cardiac cycle. During relaxationor diastole blood flows into the ventricles and the contractionthat follows, termed systole, propels blood out of the heart.The heart functions as a unit because both atria contract si-multaneously, and then both ventricles contract. When bothatria contract the ventricles are filled to capacity, and then theventricles contract and blood is ejected into both the pul-monary and the systemic circulation. At the time of ventricu-lar contraction, the mitral and tricuspid valves are closed bythe pressure from the contraction while the pulmonic and aor-tic valves are opened. The cardiac cycle represents the actualtime sequence between ventricular contraction and ventricu-lar relaxation.

Autonomic Nervous SystemThe autonomic nervous system is a built-in control center forthe body. Its purpose is to regulate functions of the body that arenot under conscious control. There are two major divisions: thesympathetic and the parasympathetic nervous systems. Most ofthe organs of the body are innervated with both systems, al-though the blood vessels are innervated with only the sympa-thetic nervous system. The sympathetic nervous system (SNS)prepares the body for activity (flight or fight), whereas the


parasympathetic nervous system (PSNS) regulates the calmer(rest and digest) functions. Because the sympathetic nervoussystem (SNS) and the parasympathetic nervous system (PSNS)innervate the heart, neural impulses are not needed to maintainthe cardiac cycle. In other words, the heart will beat in the ab-sence of any nervous system connection. The SNS and the PSNSaffect only the speed of the cardiac cycles and the diameter of thecoronary arteries. It is said that these nervous systems only “fine-tune” the cardiac cycle.

Receptors and NeurotransmittersThe nerve endings of both the SNS and the PSNS secrete neuro-transmitters. The SNS has two types of receptors at the nerveendings, the alpha- and the beta-receptors. These nerve endingsare called adrenergic. The neurotransmitter for the SNS is nor-epinephrine, which causes an increase in heart rate and contrac-tile force of the cardiac fibers. The PSNS nerve endings areknown as cholinergic, and the neurotransmitter is acetylcholine,which causes the heart rate and blood pressure to go down.

HistoryA thorough history will help the nurse identify cardiovascularsymptoms as well as current or potential problems that may af-fect cardiovascular function. Information learned from a thor-ough history and physical exam could help prevent undesirableresponses to current therapies and treatment plans. The essen-tial assessment data included in the cardiovascular history areoutlined in this section.

Biographic and Demographic DataAssessment of biographic and demographic data includes infor-mation regarding age, race, gender, and ethnicity, which can im-pact the susceptibility to some cardiovascular disorders. Forexample, African Americans have a higher incidence of hyper-tension than Caucasians (American Heart Association, 2005),and premenopausal women have a lower incidence of atheroscle-rotic coronary artery disease than men (American Heart Associ-ation, 2008). Additionally, the presenting symptoms ofcardiovascular diseases in women are often atypical, which mayeither delay diagnosis or make diagnosis more difficult. For ex-ample, women more frequently present with shortness of breath.

Chief ComplaintDuring the assessment process the nurse obtains a complete de-scription of the present illness, paying particular attention tothe chief complaint, or the reason the patient is seeking healthcare. The chief complaint focuses the history-taking processand prioritizes treatment regimens. For example, if the patientis complaining of chest pain, then the history should include in-formation regarding the nature of the pain, associated symp-toms, exacerbating and alleviating factors, as well as radiation ofthe pain and intensity of the pain. It also is important to deter-mine what brings the pain and what relieves it.

Presenting SymptomsSymptomatology is the review of symptoms the patient is experi-encing. A review of symptoms helps define the current functionalstatus of the patient. The nurse needs to ask questions about the

date and mode of onset of the symptoms to find out when andhow the symptoms first began. For example, has the shortness ofbreath been a problem for many weeks, or is it a new occurrence?Have the symptoms changed in intensity or duration? Addition-ally, questions about the exacerbations, or what causes the symp-toms to worsen, and alleviating factors are important.

Specific Cardiovascular Clinical ManifestationsPatients with cardiovascular disease often present to the health careprofessional with typical or common cardiovascular symptoms.Knowledge of these common symptoms, their usual presentation,and their etiology can help focus and guide the exam process.

1. Nurses should be particularly aware of the followingcommon cardiovascular symptoms: chest pain,palpitations, dyspnea, orthopnea, cough, and nocturia.

2. The most severe symptoms should be assessed in greaterdepth and reported to the health care provider, if indicated.

The most life-threatening symptoms should be addressed first.If the patient is complaining of shortness of breath, it needs to beassessed immediately. Airway management and oxygen statusmust be stabilized before the remainder of the assessment is com-pleted. The management of airway is discussed in Chapters 34, 35,and 36 . Next, the patient is asked about the presence, site, andintensity of pain. The primary cardiovascular concern is pain as-sociated with cardiac muscle ischemia, referred to as angina pec-toris. The clinical manifestations of angina vary among patients;therefore, specific questions must be asked during the assessmentin order to ascertain the cause of the pain. Pain may be describedas indigestion, burning, numbness, tightness, or pressure in themidchest, or as epigastric or substernal pain, which can radiate tothe shoulder, neck, arms, jaw, or back. It is essential that the nurseinquires about what brings the “pain on” and what makes it goaway. An in-depth discussion of angina-type chest pain, the as-sessment data, and treatment is included in Chapter 40 . Pa-tients might deny the presence of chest pain but admit tosensations of chest discomfort; therefore, it is important to allowpatients to present their symptoms in their own words prior to an-alyzing their symptoms.

Palpitations are typically described by the patient as sensa-tions of a racing heartbeat, irregular beats, or skipped beats.These sensations may be normal, or they may signify cardiacrhythm disturbances. The presence of dyspnea, or shortness ofbreath, may indicate an imbalance of arterial oxygen supplyand demand. Orthopnea, the presence of dyspnea when thepatient lies flat, is frequently a manifestation of cardiac disease.Often the degree of orthopnea is measured by the number ofpillows (for example, 2- to 3-pillow orthopnea) necessary forthe patient to use to breathe comfortably while sleeping. Acough may suggest pulmonary congestion resulting from fluidaccumulation in the lungs due to either cardiac pump failureor fluid overload. If the patient has nocturia, the need to uri-nate often at night, it may indicate heart failure, although thereare other disorders that cause frequent urination, such as anenlarged prostate. During the day as a patient is up and mov-ing, fluid shifts to extremities and extravascular spaces, whichserves to decrease fluid workload on a decompensated heart.At night, however, when the patient lies flat, fluid is returned

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to the central intravascular column, thereby increasing theamount of fluid to the kidneys. Patients with heart failure mayreport paroxysmal nocturnal dyspnea, which is acute dyspneacaused by lung congestion and edema that occurs suddenly atnight, usually an hour or two after falling asleep.

Edema, or fluid accumulation in the extravascular spaces ofthe body, may be due to decreases in venous return. Fluid reten-tion is manifested by weight gain, a feeling of being bloated, orclothes or shoes that no longer fit comfortably. Changes inweight should be specifically addressed. Large, sudden weightgains correlate with volume overload. Dizziness, syncope (faint-ing), or light-headedness may be experienced with suddenchanges of position, and all are related to decreased cardiac out-put, which decreases blood to the brain.

Fatigue is a common complaint with cardiovascular pa-tients. Fatigue is due to a decreased supply of oxygen to the tis-sues. Metabolic demands are higher in chronic cardiovascularconditions; however, due to a lowered cardiac output, de-mands are not met and the result is fatigue. The fatigue is usu-ally progressive over time, and the patient may reportdecreased ability to complete usual activities of daily living.Additionally, patients may report a lack of energy or the needfor more rest than usual. Medications such as diuretics, beta-adrenergic blockers, calcium channel blockers, digoxin, andantihypertensives have long been thought to contribute to fa-tigue. For example, beta-adrenergic blockers block the re-sponse from the beta nerve receptors, which serves to slowdown the heart rate and lower the blood pressure. This desiredphysiological change, which decreases the myocardial oxygendemand, also may cause an undesired side effect of fatigue. In-terestingly, clinical trials have not supported the notion thatbeta-adrenergic blocker therapy is associated with substantialrisks of side effects. In a quantitative review of randomized tri-als that tested beta-adrenergic blockers in myocardial infarc-tion, heart failure, and hypertension, the authors found nosignificant increased risk of depressive symptoms and onlysmall increased risks of fatigue and sexual dysfunction (Ko et al.,2002). Therefore, the risks of adverse effects (fatigue) shouldbe considered in context with the well-documented benefits ofmedications such as beta-adrenergic blockers.

Problems with the peripheral vascular system are frequentlymanifested with intermittent claudication. The patient reportspain in the muscles of the lower extremities associated with ac-tivity, which may be due to arterial insufficiency. Chapter 43includes a complete discussion of both venous and arterial pe-ripheral vascular disorders.

Past Medical HistoryPast medical history should be reviewed because many past ill-nesses or disorders of other systems of the body can affect the car-diovascular system directly or indirectly. Additionally, the clinicalmanifestations of other diseases may mistakenly be attributed tocardiovascular disorders. For example, it is important to deter-mine the presence of respiratory disorders to assess a patient’scomplaint of dyspnea properly, or a history of rheumatic heartdisease may have damaged the heart valves. Unit 7 discussesrespiratory management, and Chapter 41 discusses rheu-matic fever and valve disorders.

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Childhood Illnesses and ImmunizationsChildhood illnesses, congenital heart diseases, history of mur-murs, cyanosis, streptococcal infections, anemia, and rheumaticfever should all be assessed. They can either exacerbate currentcardiovascular conditions or contribute to the development ofadditional cardiovascular problems and disease states. Nursesshould question the status of immunizations and make surethey are up-to-date.

Previous Illnesses and HospitalizationsHeart failure, coronary artery disease (CAD), stroke, heartvalve disease, mitral valve prolapse, previous myocardial in-farction (MI), peripheral vascular disease (PVD), diabetesmellitus (DM), hypertension (HTN), hyperlipidemia, dys-rhythmias, murmurs, endocarditis, psychiatric illnesses,thrombophlebitis, deep vein thrombosis (DVT), and systemicor pulmonary emboli are all important components of or con-tributors to cardiovascular disease. Their presence, or a historyof their presence, and the potential impact on the presenthealth state must be assessed.

Diagnostic/Interventional Cardiac Proceduresor SurgeriesData from previous diagnostic tests, particularly for cardiovas-cular symptoms, should be obtained. The patient should beasked whether he had any cardiac studies or interventions in thepast such as cardiac catheterizations, cardiac ultrasounds, elec-trocardiograms (ECGs), exercise tolerance tests (stress tests), ormyocardial imaging. Previous chest x-rays or ECGs may behelpful to view for baseline data.

Past surgeries, treatments, or hospital admissions should beexplored. Assess for a history of previous percutaneous translu-minal coronary angioplasty (PTCA), atherectomy stent place-ment, or valvuloplasty. See Chapter 39 for more informationon diagnostic and interventional therapies for heart disease.

MedicationsThe patient’s current and past medications should be reviewed.This includes over-the-counter (OTC) and any prescriptionmedications. A medication list with the name and dose of eachmedication and the patient’s understanding of its purpose ishelpful. The consumption of herbal remedies or dietary supple-ments should be specifically assessed because some cardiovas-cular complications have been linked to these substances.Consideration is made of other common medications and theirpotential side effects on cardiovascular status. Chart 37–1 out-lines common medications and their side effects that affect thecardiovascular system.

Cultural ConsiderationsHealth and well-being of a culturally diverse population can bepromoted by incorporating the therapies that patients have tra-ditionally used. The basis for many complementary therapies isto promote harmony, promote health, reduce anxiety, and in-crease comfort (Snyder & Miska, 2003). During the assessmentphase, nurses must be able to gather information on the use ofall therapies being used by a patient, including complementaryand nontraditional therapies, as discussed in the Complemen-tary and Alternative Therapies box, in order to plan care that issafe and comfortable.

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CHART 37–1 Common Medications and Side EffectsThat Affect Cardiovascular Status

AllergiesCertain diagnostic tests to evaluate heart disease use contrastmedia and medications, so the presence of any allergies, espe-cially to radiographic contrast agents or iodine, should be as-sessed. Drug interactions or intolerance should also be noted.Information as to the nature of allergic reactions, such as rash,anaphylaxis, or dyspnea, is essential.

Family HistoryThe link between familial history of cardiovascular disease andthe risk for similar events is well established (Williams et al.,2001). Specifically, the patient should be asked whether blood rel-atives have suffered from any of the following: coronary artery

disease (CAD) at or under age 55, myocardial infarction, hyper-tension, stroke, diabetes mellitus, and/or lipid disorders. Collagenvascular diseases such as lupus or scleroderma may be important,because they are linked to the development of cardiac disease orpericarditis. Additionally, a family health history of noncardiacconditions such as asthma, renal disease, and obesity should benoted due to their impact on cardiovascular function.

Risk FactorsIt is necessary to assess for the presence of risk factors to antici-pate the likelihood of the development of cardiovascular disor-ders. Risk factors can be classified as either nonmodifiable ormodifiable. Nonmodifiable risk factors are not subject to inter-ventions to decrease their significance yet play an important rolein the development of cardiovascular diseases. Nonmodifiablerisk factors include such things as age, gender, family history, andrace. Modifiable risk factors are those that can be treated with in-terventions to decrease their impact on the development of thedisorder. Modifiable risk factors include cigarette smoking, hy-pertension (HTN), hypercholesterolemia, physical inactivity, di-abetes, stress, and obesity. Chapter 40 includes a completedescription of cardiac risk factors. Additionally, recent dentalwork or infection may put the patient at risk for development ofcardiac complications such as endocarditis. Another risk factorassociated with cardiovascular disorders is metabolic syndrome,as discussed in the Risk Factors box.

Social HistoryAn assessment of social history is important because of the rela-tionship between social history and the development of, acceler-ation of, and response to cardiovascular diseases. Risk factorassessment and history taking are done simultaneously. Whiletaking a social history, nurses can gain valuable informationfrom the patient about the presence of risk factors. Nurses then

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Medication Side Effect

Anabolic steroids Increased total cholesterol, decreasedHDL, hypertrophy

Antihistamines Dysrhythmias, syncope

Aspirin Prolonged blood clotting time

Corticosteroids Sodium and fluid retention

Decongestants Hypertension and arrhythmias

Doxorubicin (Adriamycin) Cardiomyopathy

Lithium Dysrhythmias

Oral contraceptives Thrombophlebitis

Phenothiazines Dysrhythmias, hypotension

Recreational or abused drugs Tachycardia, dysrhythmias

Theophylline preparations Tachycardia, arrhythmias

Tricyclic antidepressants Dysrhythmias

ONE OF THE MOST important complementary therapies that shouldbe addressed during assessment is the use of herbal products. There is aknown risk of interaction between herbal products and conventional med-ications.

Research Support:A study by Yoon and Claydell (2001) explored the use of herbal products formedicinal purposes and compared differences in demographic character-istics and health status of herbal product users and nonusers amongcommunity-dwelling older women. In 1998, a random sample of 86 womenaged 65 years and older who lived independently in a north central Floridacounty was selected. Questionnaires were completed for the 86 subjects.Findings indicated that herbal products had been used by 45% of the sam-ple in the previous 12 months.The average number of herbal products usedby the 45% was 2.5. Herbal products were used to prevent health problems(41%), to treat illness (23%), and for both prevention and treatment (36%).The three most commonly used herbal products were ginkgo biloba orginkgo biloba with other combinations, garlic tablets and cloves, and glu-

cosamine with chondroitin. The women reported using an average of 3.2prescribed medicines and 3.8 nonprescribed medicines. The most fre-quently used nonprescribed medicines taken regularly were multivitamins,calcium, vitamin E, vitamin C, and aspirin. Interestingly, there were no dif-ferences in demographic characteristics and health status for users andnonusers of herbal products except that herbal product users were moreconcerned with memory problems than were nonusers (Yoon & Claydell,2001). The implications for nurses are that it is important for health careproviders to be knowledgeable about the use of herbal products to providecomprehensive health care. In order to make these needed adaptations ofcare, nurses must be knowledgeable and committed to provide culturallycompetent care.

ReferencesYoon, S., & Claydell, H. (2001). Herbal products and conventional medicines

used by community-residing older women. Journal of Advanced Nurs-ing, 33(1), 51–59.

COMPLEMENTARY &

ALTERNATIVE THERAPIES Herbal Products


RISK FACTORS Related to Metabolic Syndrome

The metabolic syndrome describes a cluster of risk factors thatsignificantly increases the incidence of an acute cardiac event andother diseases related to plaque buildup in artery walls (e.g., strokeand peripheral vascular disease) and type II diabetes. The metabolicsyndrome has become increasingly common in the United States. Itis estimated that over 50 million Americans have it (American HeartAssociation [AHA], 2008a). The Third Report of the NationalCholesterol Education Program Expert Panel on Detection, Evaluation,and Treatment of High Blood Cholesterol in Adults (Adult TreatmentPanel III) (ATP III) defines and describes the importance of metabolicsyndrome. Individuals having three or more of the following criteriaare defined as having the metabolic syndrome (National Institutes ofHealth, 2001; AHA, 2006):

• Abdominal obesity: waist circumference > 102 cm in men and> 88 cm in women

• Hypertriglyceridemia: > 150 mg/dL (1.69 mmol/L)

• High high-density lipoprotein (HDL) cholesterol: < 40 mg/dL(1.04 mmol/L) in men and < 50 mg/dL (1.29 mmol/L) in women

• High blood pressure: > 130/85 mmHg

• High fasting glucose: > 110 mg/dL (>6.1 mmol/L)

• Prothrombotic state (e.g., high fibrinogen or plasminogen activatorinhibitor–1 in the blood)

• Proinflammatory state (e.g., elevated C-reactive protein in the blood).

Abdominal obesity, elevated triglycerides, and insulin resistance(a metabolic disorder in which the body is unable to use insulinefficiently) are major features in metabolic syndrome and have acomplex relationship. Fat accumulation in the lower body (pear-shaped) is subcutaneous, whereas fat accumulation in the abdominalarea (apple-shaped) is largely visceral fat. Excess abdominal fatdisrupts the normal balance and functioning of several hormones,including lipids and insulin. Abdominal fat and circulatingtriglycerides both increase with age, and recent studies haveconfirmed their relationship as major metabolic risk factors (Kahn &Valdez, 2003). Therefore, waist circumference measurement, as ameasure of abdominal fat, is a useful tool in physical assessmentand is a reliable, inexpensive indicator that helps identify those atrisk for lipid accumulation. While assessing risk factors, nursesshould be aware that individuals with metabolic syndrome are at agreater risk for developing cardiovascular disease than areindividuals without metabolic syndrome (Kahn, Buse, Ferrannini, &Stern, 2005). Other conditions commonly associated with metabolicsyndrome include physical inactivity, aging, hormonal imbalance, andgenetic predisposition. Metabolic syndrome is discussed in depth inChapter 40 .

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have an important role in assisting patients to recognize un-healthy habits that require education in order to modify orchange to prevent the progression and complications associatedwith the development of cardiovascular disorders. As nurses de-velop relationships with patients, they are in a unique position tooffer assistance in risk factor analysis and lifestyle modification.The identification of the presence of modifiable risk factors, aswell as the patient’s ability and interest in adopting lifestylechanges, forms a framework for the nursing discharge teachingplan discussed in the subsequent cardiac disorder chapters.

OccupationJob stress is a common condition that promotes the occurrenceof cardiovascular events. Previous and recent job-related stres-

sors should be explored. Stress and tension regardless of theiretiology cause vasoconstriction, which increases afterload, oxy-gen consumption, and release of catecholamines, which in turncan contribute to the development of cardiac symptoms. An-other occupational hazard that should be considered is exposureto noxious or harmful substances, and the potential effect ofthem on the cardiovascular system.

CultureNurses should be prepared to care for a diverse group of people,because the numbers of patients from other cultures in thehealth care system have increased. There is a great deal of varia-tion in cultural consistency of different demographic areas. Be-liefs and values related to health, illness, and death, as well asdaily habits, nutritional preferences, and health practices, mayexist that are culturally important to the patient, but conflictwith the health care environment or even the function of thecardiovascular status. Nurses may need to ask questions aboutupcoming religious celebrations or rituals that might affect di-etary patterns or preferences (Smith-Stoner, 2006). For exam-ple, the patient should be asked about the salt content in thefood, because an increased amount may precipitate an episodeof heart failure or high blood pressure. As nurses are caring formore diverse populations, they need to be knowledgeable aboutthe health practices of other cultures and religions.

EnvironmentEnvironment and lifestyle issues are also strongly correlated withthe risk for cardiovascular disease. Environmental conditionssuch as living conditions and the presence of any cardiovasculartoxins may need to be addressed. It is understood that heart dis-ease develops as a result of complex interactions between genesand the environment in which we live (Bhatnagar, 2006). Envi-ronmental risk factors are not limited to the better known risk fac-tors of smoking, poor diet, and lack of exercise, but also includeexposure to pollutants and chemicals. Similarly to the response tosecondhand smoke, cardiovascular tissues are extremely sensitiveto environmental chemicals and pollutants; therefore, environ-mental exposures should be routinely considered during cardio-vascular assessment. Specifically, nurses should assess forexposure to particulate matter, arsenic, or metals. Further re-search is needed to determine the relationship of environmentalchemicals and cardiovascular toxicity (Bhatnagar, 2006).

HabitsLifestyle habits and dietary habits such as the use of tea, coffee, al-cohol, recreational drugs, over-the-counter drugs, and smokingshould be discussed and documented. If the patient smokes, thenumber of pack years of smoking (packs smoked per day multi-plied by the years smoked) should be calculated. The patient’s atti-tude about smoking and any attempts to stop smoking should bedocumented. The presence of secondhand smoke also must be as-sessed. Alcohol use, including type of beverages, amount, fre-quency, and any change in the reaction to it should be assessed. Theuse of habit-forming drugs and recreational drugs should be noted.

ExerciseThe practice of engaging in physical activity has long beenknown to reduce the risk of cardiovascular events. Low levels ofphysical activity as well as consumption of excess calories, com-bined with inherited genes, cause obesity. Obesity, especially ab-


dominal obesity, is a predisposing factor for the development ofcardiovascular disease as well as hypertension and type II dia-betes mellitus. The physical activity patterns of a patient, includ-ing the type of exercise, the duration and frequency of theexercise, and the presence of any cardiovascular symptoms,should be documented. Any decrease in previous abilities orchanges in the response to physical activity should be noted, be-cause they may be indications of the advent or progression ofheart disease.

In 1996 with revisions in 1999, the Surgeon General of theUnited States Public Health Service published a report on phys-ical activity and health. This report contains a comprehensivereview of scientific evidence about the relationship betweenphysical activity and health status in an attempt to heightenAmerica’s awareness of this important public health issue. Thereport makes it clear that current levels of physical activityamong Americans remain low; however, the emphasis is thatpeople can benefit from even moderate levels of physical activ-ity, and that even greater health benefits can be achieved by in-creasing the amount (duration, frequency, or intensity) ofphysical activity (Centers for Disease Control and Prevention[CDC], 2008). The report suggests that adults should strive tomeet either of the following physical activity recommendations.

• Adults should engage in moderate-intensity physical activitiesfor at least 30 minutes on 5 or more days of the week (Centersfor Disease Control and Prevention, 1999).

OR

• Adults should engage in vigorous-intensity physical activity 3 ormore days per week for 20 or more minutes per occasion (U.S.Department of Health and Human Services [DHHS], 2004).

NutritionIt is important to assess the patient’s weight and diet history.An assessment of weight in comparison to height and buildmust be completed. Being overweight or underweight eithermay be related to certain cardiovascular disorders or may putthe patient at risk for developing certain cardiac problems.Usual dietary intake including amounts of salt, saturated fats,triglycerides, and fluids should be determined. It may be im-portant to identify which dietary habits are related to culturalpreferences and which habits are the results of the environmentor social situations. For example, an executive may consumemany meals at restaurants while out with clients, and a con-struction worker might eat many meals at fast-food restau-rants. In addition, the patient’s attitudes and plans in relationto diet should be discussed. Food intake patterns should be ac-countable to exercise patterns and should be complementary.

The National Guidelines box outlines the dietary guidelines forAmericans released by the American Heart Association in 2000.Choosing healthy foods can help to prevent the three major riskfactors for heart attack—high blood cholesterol, high blood pres-sure, and excess body weight. Because heart disease and high bloodpressure are major risk factors for stroke, these dietary guidelinesalso help prevent stroke (American Heart Association, 2006).

Personal FactorsBaseline cognitive functioning, recent life changes especiallywithin the last 12 months, sleep-rest patterns, and relationship

issues should all be considered. Emotional state, such as the ev-idence of psychological stress, anger, anxiety, or depression,causes the release of catecholamines, which results in vasocon-striction, thereby increasing cardiac workload and potentiallyresulting in a decreased cardiac output. Perception of illness andits meaning for the future should also be noted.

Personality type may also be a consideration for cardiovascu-lar assessment. Type A personality behavior has been associatedwith increased incidence of cardiovascular disease. Researchershave found conflicting evidence to support or refute this notion.Gallacher, Sweetman, Yarnell, Elwood, and Stansfeld (2003) sug-gest that increased exposure to circumstances that induce ex-treme cardiovascular activity, as seen in type A personalitybehavior, may be a “trigger” that precipitates coronary eventsrather than affecting the process of atherosclerosis. The role ofstress and the manner in which an individual deals with lifestressors may also have an important role. Individuals with type

NATIONAL GUIDELINES for Diet

American Heart Association 2006 Diet and Lifestyle RecommendationsAchieve an Overall Healthy Eating Pattern

• Choose an overall balanced diet with foods from all major foodgroups, emphasizing fruits, vegetables, and grains.

• Consume a variety of fruits, vegetables, and grain products.

• Eat at least 5 daily servings of fruits and vegetables.

• Eat at least 6 daily servings of grain products, including wholegrains.

• Include fat-free and low-fat dairy products, fish, legumes, poultry,and lean meats.

• Eat at least 2 servings of fish per week.

Achieve a Healthy Body Weight

• Maintain a level of physical activity that achieves fitness andbalances energy expenditure with caloric intake; for weightreduction, expenditure should exceed intake.

• Limit foods that are high in calories and/or low in nutritional quality,including those with a high amount of added sugar.

Achieve a Desirable Cholesterol Level

• Limit foods with a high content of saturated fat and cholesterol.Substitute with grains and unsaturated fat from vegetables, fish,legumes, and nuts.

• Limit cholesterol to 300 milligrams (mg) a day for the generalpopulation and 200 milligrams a day for those with heart disease orits risk factors.

• Limit trans fatty acids. Trans fatty acids are found in foodscontaining partially hydrogenated vegetable oils such as packagedcookies, crackers, and other baked goods; commercially preparedfried foods; and some margarines.

Achieve a Desirable Blood Pressure Level

• Limit salt intake to less than 6 grams (2,400 milligrams sodium) perday, slightly more than 1 teaspoon a day.

• If you drink, limit alcohol consumption to no more than one drink perday for women and two drinks per day for men.

Source: American Heart Association. (2006). Dietary guidelines: At-a-glance. RetrievedJanuary 21, 2008, from http://www.americanheart.org/presenter.jhtml?identifier=851.


A personality may respond to stress with hostility or aggression,which may exaggerate sympathetic and hemodynamic responsesleading to greater cardiovascular reactivity (Schroeder et al., 2000).

Physical ExaminationA thorough physical examination is the foundation for accurateassessment of the cardiovascular system and encompasses skillsof inspection, palpation, and auscultation. Percussion is not uti-lized for assessment of the cardiovascular system.

Inspection of Skin and ExtremitiesA great deal of information can be obtained about the status ofthe cardiovascular system by simply observing and touching thepatient. An experienced nurse is able to assess general appearancequickly, including facial expressions, body posture and menta-tion, as well as color and temperature, and clubbing of the nailbeds. Then it is necessary to relate the findings to the patient’s cur-rent cardiovascular status.

General AppearanceGeneral appearance includes a brief visual inspection of a pa-tient’s physical appearance. Observations of a patient who looksunwell, lethargic, exhausted, or breathless are important findingsand may indicate reduced cardiac output or heart failure. Anobese person who has fat evenly distributed over the body is vul-nerable for serious cardiovascular health consequences. Addi-tionally, an accumulation of abdominal (visceral) fat, measuredby waist circumference, is a known risk factor for cardiovascularand other diseases.

Interestingly, recent studies suggest that variances in fat dis-tributions (abdominal vs. peripheral) may exhibit different in-fluences on lipid metabolism. Laszlo et al. (2004) studied 1,356women aged 60 to 85 years and found that abdominal fat masspromoted atherogenesis, whereas peripheral fat deposits actu-ally counteracted atherogenesis. The women with peripheral fatdeposits rather than central fat deposits showed a negative cor-relation with glucose and lipid metabolites. The authors con-cluded that the localization or distribution of the fat mass is animportant consideration in obese patients and should be con-sidered during any risk appraisal.

Observation of facial expression may indicate important find-ings, such as the assessment of apprehension, pain, or fear. Bodyposture may indicate the amount of effort it takes to breathe. Forexample, a patient in acute heart failure may need to sit upright,whereas a patient with pericarditis may lean forward in order tobreathe comfortably (Urden, Lough, & Stacy, 2006).

MentationAdequate functioning of all subsystems of the body indicates theindividual organ is receiving adequate cardiac output. For exam-ple, normal neurological function indicates adequate cerebralperfusion. A quick and easy method to estimate baseline cogni-tive function is to assess the patient’s orientation to person, placeand time, and situation. Confusion could indicate hypotensionor low cardiac output.

Color and Appearance of Skin and ExtremitiesThe skin and mucous membranes are inspected for color andtemperature. Extremities should be assessed bilaterally for equaltemperature and appearance. The extremities are inspected for

signs of peripheral arterial or venous vascular disorders. Arter-ial vascular disease is suspected when the skin is pale, shiny, withsparse hair growth. Venous vascular diseases cause an edema-tous limb with deep red rubor, brown discoloration, and leg ul-cerations (Urden, Lough, & Stacy, 2006). Chapter 43includes an in-depth description of peripheral vascular disease.

CyanosisCyanosis is a bluish tinge to the skin due to deoxygenated he-moglobin in the blood vessels close to the skin surface; it can beeither central or peripheral. Central cyanosis, which is noted onthe lips or tongue, is often characteristic of impaired gas ex-change. Central cyanosis may result from a cardiac right-to-leftshunt due to septal defects, in which deoxygenated venous bloodmixes with blood from the left heart and is ejected into the sys-temic circulation. In heart failure with significant pulmonarycongestion, oxygenation of blood in the pulmonary vascularbed can be impaired, which leads to deoxygenated blood return-ing to the left heart and being pumped out into the systemic cir-culation. Peripheral cyanosis, which occurs in the extremities orunder the nail beds, may indicate poor circulation. The roomwhere the examination is taking place must have a comfortabletemperature because nail beds can become cyanotic with coldtemperatures.

PallorPallor suggests poor perfusion, which may be related to periph-eral vascular disease (a narrowing in the blood vessels outsidethe heart); a release of catecholamines and subsequent vasocon-striction; or a low hemoglobin and hematocrit. All of these con-ditions should be thoroughly assessed. Additionally,temperature changes such as generalized warmth or coolnessmay indicate altered peripheral perfusion.

Nail BedsClubbing of nail beds is easily assessed and appears as swellingof the subcutaneous tissue over the base of the nail and absenceof the normal angle between the nail and the nail base. The pres-ence of clubbing indicates long-term oxygen deficiencies such ascongenital heart defects or pulmonary diseases with hypoxemia.

Neck VeinsThe right external and internal jugular veins (Figure 37–5 �) areused to assess for jugular venous distention (JVD) and jugularvenous pressure (JVP) or pulse. Although these terms are oftenused interchangeably, there is a physiological significance in dis-tinguishing between JVD and JVP. Anatomically, the right jugu-lar veins drain blood from the head into the right atrium of theheart. Both veins reflect activity on the right side of the heart.The internal jugular vein lies in a straight path to the rightatrium, but because it is buried beneath the sternomastoid mus-cle, it is difficult to visualize. The external jugular vein curves afew times before entering the right atrium, and because it is lo-cated closer to the skin it is easier to visualize. Findings fromneck vein assessment are helpful in confirming suspicions ofheart failure; however, the information must be put in context ofthe presenting symptoms and current health status. The impor-tance of volume status and cardiovascular function is an impor-tant hemodynamic concept. Chapter 42 includes anin-depth discussion of the significance of distended neck veinswith heart failure.

88

88


Jugular Venous DistentionJugular venous distention (JVD) is assessed by visually observingthe right external jugular (REJ) vein. Generally noting that thisvein is full or overdistended is sufficient for the nursing assess-ment and provides useful information pertaining to hemody-namic volume status of the cardiovascular system. The REJ veinis always distended when the patient is lying flat and is eliminatedas the patient becomes more upright. From a flat position, slowlyelevate the head of the bed and observe the right external jugu-lar vein, noting the degree of elevation at which the distention iseliminated (30, 45, 60, or 90 degrees). The finding is reported bynoting the highest height of the head of the bed (HOB) whenJVD was appreciated; for example, “presence of JVD was notedwith HOB elevated to 45 degrees” (Urden et al., 2006).

The finding of JVD during inspection of the neck veins cancontribute to diagnosis of right heart failure. Treatment toreduce volume, such as diuretics or vasodilators, may beneeded. The finding of JVD may also help to explain other

findings noted during the exam, such as shortness of breath (SOB),diaphoresis, or confusion.

Jugular Venous PressureThe right internal jugular (RIJ) vein is used to assess jugular ve-nous pulses and jugular venous pressure. The RIJ lies deep inskin and soft tissues, and its pulsations are transmitted to theoverlying tissues. These pulsations are produced by the rightatrial and right ventricular activity (Garg & Garg, 2000).Changes in pulsations can be a diagnostic tool for the skilledpractitioner. Assessment of RIJ for jugular venous pressure(JVP) provides valuable information as well; and it is a morereliable indicator of central venous pressure (CVP), or thepressure that exists in the central venous system, than is theright external vein assessment. To examine the JVP, stand onthe patient’s right side, and turn the patient’s head slightly tothe left. The neck muscles should be relaxed. The head of thebed should be elevated high enough to visualize the top of the

column of blood in the internal jugular vein. Observe the high-est point of pulsation during exhalation. The vertical differencebetween this location and the sternal angle (see Figure 37–5 �)is measured in centimeters. The normal measurement shouldbe 4 centimeters or less. A measurement of more than 4 cen-timeters suggests increased JVP, an increase in pressure in theright heart, and therefore an increased CVP. Because the dis-tance between the sternal angle and the mid-right atrium is ap-proximately 5 centimeters, to measure CVP, 5 centimeters isadded to the measurement of JVP. The upper limit of normal isa CVP measurement of 9 centimeters (JVP of 4 plus 5 centime-ters) (Garg & Garg, 2000). An example of how this finding is re-ported is “JVP estimated at 9 centimeters with the head of thebed elevated to 45 degrees.”

Abdominojugular RefluxThe assessment of the abdominojugular reflux (sometimescalled hepatojugular reflux) can also be used as a noninvasivetechnique to assess cardiovascular volume status. In heart failure,or volume overload, blood volume that normally is pumped pro-ficiently by the heart begins to be displaced throughout the bodyas a mechanism to minimize cardiac workload. Volume may bedisplaced in the abdomen, particularly the hepatic system, whichhas a large capacity to hold fluid. The technique to observeabdominojugular reflux is done by compressing the right upperabdomen for 15 to 30 seconds. Observe for JVD before, during,and after abdominal compression. This pressure causes volumein the abdomen to be pushed back to the right atrium. The fail-ing heart will not be able to accommodate this increase in vol-ume, and the pressure will be reflected in the jugular veins.Sustained JVD (longer than 10 seconds) with abdominal com-pression is another indicator that aids the diagnosis of cardiacfailure (Urden et al., 2006).

Palpation of Skin and ExtremitiesPalpation of the skin and extremities during a cardiovascular as-sessment includes an assessment of edema, skin turgor, capillaryrefill, and the arterial pulses for abnormalities associated withcardiovascular disorders.

EdemaEdema is defined as an increase in interstitial fluid that is clini-cally evident. Although there are many types of edema, cardio-vascular patients typically experience edema associated with theaccumulation of fluid in the extracellular spaces, particularly theskin of the extremities, as seen earlier. Edema of the skin can bepainful, and it interferes with normal blood circulation. Edemais an important assessment finding because it is indicative of anunderlying disease process and requires treatment.

Normally two-thirds of the body’s water is in the cells (intra-cellular), while one-third is outside the cells (extracellular). Ex-tracellular fluid consists of water in the plasma and in the tissues(interstitial). Fluid exchange between these compartments isgoverned by a balance of hydraulic and oncotic pressures as wellas the permeability of the capillary wall that separates them.When any of the factors are altered, excess fluid may be movedinto the plasma and interstitial spaces. Changes in capillary hy-draulic pressure can occur with heart failure. Capillary perme-ability can be increased as a consequence of the inflammatoryprocess, which can be initiated as a response to numerous events

FIGURE 37–5 � Jugular veins.

Externaljugular vein

Internaljugular vein

30º

Venouspressure

Sternalangle


CHART 37–2 Scale for Rating Edema

including exposure to allergens. The kidneys play an importantrole in body fluid distribution as the kidneys respond to changesin blood pressure and volume by adjusting retention of sodium.Therefore, sodium balance is of utmost importance in cardio-vascular disease processes involving the development or poten-tial development of edema.

The skin can feel puffy and tight. Edema can be localized inone area of the body or can be generalized throughout. Depen-dent edema occurs when there is an increase in extracellular fluidvolume in a dependent limb or area. Edema is assessed by firmlyplacing a thumb against a dependent area of the body (arms,hands, legs, feet, ankles). When the pressure is released, an inden-tation on the skin may be observed. When the indentation re-mains on the skin after releasing pressure, it is referred to aspitting edema. The degree of pitting edema can be rated on a4-point scale (Chart 37–2).

Skin TurgorPalpation of the skin turgor, or elasticity, reflects the skin’s stateof hydration. A small section of the patient’s skin (anterior chest,under clavicle, or abdomen) is pinched between the examiner’sthumb and forefinger. As the skin is slowly released, the speed atwhich the skin returns to its original contour is observed. Itshould return to normal rapidly. If there is poor skin turgor, theskin returns to its original contour very slowly. Dehydration,scleroderma, or aging can decrease skin turgor.

Capillary RefillCapillary refill, the rate at which blood refills empty capillaries, isa quick method of assessing blood flow to the peripheral micro-circulation. The tip of the finger is compressed until blanching ofthe nail bed is noted. When pressure is released, a return of colorshould be noted within 2 to 3 seconds. A delayed return of coloris a sign of vasoconstriction or poor peripheral perfusion. A de-layed capillary refill may be observed in heart failure, peripheralvascular disease (PVD), or shock.

Arterial PulsesPalpation of the pulses in the neck and extremities provides in-formation about arterial blood flow, particularly volume andpressure within the vessels. Arterial pulses are palpated bilater-ally to compare characteristics of the arteries on the right andleft sides of the body (Figure 37–6 �). The volume of the pulsa-tions is judged and recorded as normal, bounding, thready, orabsent. Additionally, a common scale can be used for documen-tation of pulses. A score of 0 indicates an absent pulse. A scoreof 1+ indicates a pulse is present, but it is weak and thready. Ascore of 2+ indicates a pulse is present and normal in amplitude.A score of 3+ indicates a full and bounding pulsation. A normal

pulse feels like a tap, whereas a vessel that is narrowed or bulgingwill vibrate. The rate and rhythm of arterial pulses are palpated.The examiner counts the number of pulsations in a minute todetermine the heart rate. At the same time, a judgment is madeas to the regularity of the pattern of pulses and the intervals be-tween pulses. Pulses can be normal or abnormal. Abnormalitiesin rate and rhythm of arterial pulses may indicate inadequatecardiac output or cardiac dysrhythmias.

Inspection and Palpation of the PrecordiumInspection and palpation of the bony structures of the thorax,including the sternoclavicular joints, the manubrium, and theupper part of the sternum, are performed using clinical refer-ence points. The precordium is assessed for pulsations, heaves,and thrills described below, which may indicate vessel abnor-malities.

Clinical Reference PointsThe normal clinical reference points or landmarks of the chestwall, as well as specific auscultatory areas, should be noted onevery patient during cardiovascular assessment in a consistentmanner. Experience enhances the ability to identify abnormali-ties and their significance to cardiovascular disorders (Figures37–7 and 37–8).

Point of Maximal Impulse (PMI)The mitral valve area of the thorax is palpated for the point ofmaximal impulse (PMI). This pulsation is normally located atthe left fifth intercostal space (ICS) at the midclavicular line(MCL) (see Figure 37–7 �). With the patient in a sitting posi-tion, the nurse uses fingertips to identify the PMI. Sometimeshaving the patient lean slightly forward enhances the PMI. The

�0�� No pitting

�1 0��1/4�� pitting (mild)

�2 1/4��1/2�� pitting (moderate)

�3 1/2��1�� pitting (severe)

�4 Greater than 1�� pitting (severe)

FIGURE 37–6 � Arterial pulses.

Systemic Circulation

Arteries

Apical

Radial

Pedal

Posteriortibal

Right sternal border (RSB), 2nd intercostalspace (ICS)

Left sternalborder (LSB), 2nd ICS

LSB, 3rd ICS

LSB, 4th ICS

Midclavicularline (MCL), 5th ICS

Point of maximalimpulse

12

3

4

5

6

7

8


PMI is normally felt as a single pulsation or light tap, and is 1 to2 centimeters in diameter. The position and the diameter of thePMI should be recorded in relation to the MCL and ICSs. If thepatient has an enlarged heart (cardiomegaly) due to heart fail-ure, ventricular hypertrophy, or pregnancy, the PMI may be en-larged or displaced laterally and downward. The PMI may alsobe visualized as a pulsation on the chest in a patient with cardio-vascular disease.

Heaves and ThrillsThe precordium is inspected for pulsations, heaves, and thrills.Although rare, pulsations may be visualized on the chest wall,particularly in thin patients, and may be caused by pulmonaryhypertension or a significant aneurysm. Heaves or lifts, whichare normally not seen or felt over the precordium, are sustainedlifts of the chest wall in the precordial area due to forceful car-diac contractions that cause a slight to vigorous movement ofthe sternum and ribs. Heaves may be caused by ventricular en-largement or hypertrophy. A thrill describes a palpable vibra-

tory sensation from turbulent blood flow across cardiac valves.Thrills are typically described as the throat of a purring cat.

Findings in various clinical reference points may indicate spe-cific cardiac disorders. The respiratory system is observed si-

multaneously, because the purpose of the cardiovascularsystem is to deliver oxygen to the tissues that was receivedfrom the respiratory system. Alterations in rate and depthof respirations may indicate cardiovascular, respiratory, orneurological disorders.

Auscultation of the PrecordiumAuscultation involves listening to the sounds produced by

different body areas. Cardiac auscultation is an efficient,noninvasive manner to assess both normal and abnormal heart

sounds. Although the technique is simply performed with onlya stethoscope, a great deal of practice and expertise is requiredto appreciate and differentiate cardiac abnormalities associatedwith valvular alterations. The art of auscultation includes theability to discriminate subtle differences in intensity, pitch, loca-tion, radiation, duration, timing, and intervals of heart sounds(O’Connor, 1998). Generally, nurses should be able to performthe technique proficiently, be able to recognize normal ausculta-tory sounds, and most importantly be alert to variations fromnormal that can provide valuable clinical clues and may indicatea change or deterioration in cardiac status.

The skill of auscultation begins with good technique and aquiet environment. The stethoscope should be of good qualitywith a bell, a diaphragm, and comfortable earpieces. The stetho-scope must be applied directly to the skin; listening over cloth-ing will obscure the sound. The patient should be in acomfortable position and asked to lie still and not talk. Imaginethe position of the heart and the cardiac valves under the chestwall (see Figure 37–8 �). Find the angle of Louis, felt as a ridgejust below the suprasternal notch (see Figure 37–5 �). Feel theribs on each side of this angle and the intercostal space beloweach rib. Using the bell and the diaphragm of the stethoscope,listen to heart sounds at each auscultatory area (see Figure37–8 �), first with the diaphragm for high-pitched sounds andthen with the bell with very light pressure for low-pitched

FIGURE 37–7 � Clinical reference points for palpation.

1 2

3

45

6

FIGURE 37–8 � Auscultatory areas.

1 2

3

4

5


sounds at each auscultatory site. Listen for the normal S1 and S2

heart sounds at each site, and note the intensity, the presence ofsplit sounds, and the effect of the respiratory cycle on the regu-larity of the sounds. Also note the time between the S1 and S2 forregularity. Listen for extra heart sounds and abnormal heartsounds at each site. If abnormal sounds are heard, note the tim-ing, pitch, loudness, duration, and location on the chest wall. Ifa murmur is heard, note where it can be heard best and whetherit is a low-, medium-, or high-pitched sound. The presence ofany pericardial friction rubs should also be noted.

Requirements for AuscultationIn order to understand cardiac auscultation, nurses need to haveknowledge of the physiology of the cardiac cycle, the normallandmarks of the chest (see Figure 37–7 �, p. 1065), and the aus-cultatory sites on the chest wall that correspond to specific valvesounds (see Figure 37–8 �, p. 1065). When listening to dynamicblood flow across cardiac valves, the sounds associated with theclosure of the valves are not heard directly over that valve area,but rather in the direction of the flow of blood. It is helpful toimagine the physical position of the heart under the chest wall,as well as the path or direction of blood flow (Figure 37–9 �).Because sound is not transmitted through bone, the best auscul-tatory area of a particular valve would be the nearest tissue areain line with the path of blood flow. The key to a good ausculta-tory exam is to listen to one sound at a time in each auscultatory

area. The nurse should be in the habit of listening to all the aus-cultatory areas with the diaphragm and then again with the bell.

Normal Heart Sounds: S1 and S2Normal heart sounds are created by the turbulence of bloodflow as the cardiac valves open and close during the cardiac cy-cle. As the valves move, some turbulence in blood flow is created.(See the Cardiac Valves section at the beginning of the chapter.)Two heart sounds can be heard with each cardiac cycle. The firstheart sound is referred to as S1 and the second heart sound, S2.S1 is a called a systolic sound because it signals the beginning ofsystole. When the pressures in the pulmonary artery and theright ventricle begin to equalize, and the pressures in the aortaand the left ventricle begin to equalize, systolic ejection tapersoff and the semilunar valves snap shut. This signals the begin-ning of diastole, which allows the AV valves to open and diastolicventricular filling to begin. The closing of the AV valves is heardas the S2, or second heart sound (Chart 37–3, p. 1067). The S1

and the S2 are both high-pitched sounds heard best with the di-aphragm. The S1 is normally loudest over the apex or mitralarea, while the S2 is best heard over the base of the heart, or theaortic area.

Distinguishing S1 from S2

It is helpful during auscultation to differentiate the S1 from theS2. When there is an abnormality, it must be described as a sys-

FIGURE 37–9 � Cardiac blood flow path.

Interventricularseptum

Right atrium

Right ventricleLeft atrium

Left ventricle

Cardiac blood flow paths

Systemicatrialcirculation

Systemic venous circulation

Systemic venous circulation

Pulmonary circulationPulmonary

circulation


tolic sound (occurring with or after the S1) or a diastolic sound(occurring with or after the S2). By determining where in thecardiac cycle the abnormality occurs, the listener can better es-timate which cardiac valve is affected. For example, if the nurse

hears an abnormality of the S1 sound, she would know there isan alteration in either the mitral or the tricuspid valve. The S1

and the S2 sounds can be differentiated by three methods. Thefirst is timing. During the cardiac cycle, the amount of time

CHART 37–3 Summary of Heart Sounds

Heart Sounds Cardiac Cycle Timing Ausculation Site Position Pitch

S1 Start of systole Best at apex with diaphragm Position does notaffect the sound

High

S2 End of systole Both at 2nd intercostal space (ICS);pulmonary component best at left sternalborder (LSB); aortic component best atRBS with diaphragm

Sitting or supine High

Split S1 Beginning of systole If normal, at 2nd ICS, LSB abnormal ifheard at apex

Better heard in thesupine position

High

Fixed Split S2 End of systole Both at 2nd ICS: pulmonary component bestat LSB; aortic component best at right sternalborder (RSB) with diaphragm


High

ParadoxialSplit S2

End of systole Both at 2nd ICS; pulmonary component bestat LSB; aortic component best at RSB withdiaphragm


High

Expiration Wide Split S2

Inspiration

End of systole Both at 2nd ICS; pulmonary component bestat LSB; aortic component best at RSB withdiaphragm

Better heard in the supine position

High

S3 Early diastole rightafter S2

Apex with the bell Auscultated better inleft lateral position orsupine

Low

S4 Late diastole rightbefore S1

Apex with the bell Auscultated better inleft lateral position orsupine

LowS1

S4

S2

S1

S3

S2

S1 S2

S1 S2

S1 S2

P2 A2

S1 S2

lub — DUB

S1 S2

S1 S2

T

S1 S2

LUB — dub


spent in diastole is longer than the amount of time spent in sys-tole. Therefore, there should be a pause between the S2 and thenext S1 (see Figure 37–10 �). Of course this method is accurateonly when the heart rate is slow enough to appreciate the dias-tolic pause. If, however, the heart rate is accelerated, the S1 canbe identified by palpating either the PMI (point of maximal im-pulse) or the carotid arterial pulsation. As the practitioner is lis-tening with the stethoscope on the chest wall to the heart sound,she should be palpating these pulsation points. When the pulsa-tion is felt, the S1 is heard. Pulse points, further downstream,such as the radial artery should not be used to establish correla-tion, because they are too far away from the heart and are notlikely to correspond with the S1.

Split Heart Sounds: Split S1 and Split S2Because the right and left heart are two separate pumps thatfunction simultaneously, it is normal to hear the closure of twovalves, the right and left AV valves, and the right and left semilu-nar valves, as one sound. Many conditions can alter the timingof the cardiac cycle on the right or left side of the heart causingone valve to close slightly later than normal. When this happens,the sounds of S1 (closure of the tricuspid and mitral valves) orthe sounds of S2 (closure of the pulmonic and aortic valves) areheard separately, referred to as a split heart sound.

The S1 is normally heard as a single sound, although theremight be a slight split between the mitral component (M1) andthe tricuspid component (T1) of the S1. The S2 exhibits a normalsplit on inspiration. This is called a physiological split, because itis associated with a normal physiological pattern. This physiolog-ical split S2, heard best over the pulmonic area, is a result of asym-metry with the closure of the aortic (A2) and pulmonic (P2) valvesounds that make up the S2 (A2P2). On inspiration, there is an in-crease in intrathoracic pressure that causes an increase in venousreturn to the right heart. The increased volume causes a delay inventricular emptying, and thus the pulmonic valve closure (P2) isslightly delayed. This effect is removed, however, during expira-tion; the A2 and P2 should be closer in synchrony, and the twocomponents of the second heart sound are heard as one. Numer-ous other conditions, such as ventricular septal defects (VSDs),bundle branch blocks, and ventricular failure, can cause abnor-mal splitting of the S2.

Extra Heart SoundsExtra heart sounds are classified in relation to their timing inthe cardiac cycle. Although the presence of an S3 or S4 can benormal, these extra heart sounds often signify cardiac disorders.Therefore, nurses should be knowledgeable about these sounds,as well as their significance in relation to heart disease, in orderto detect and report their presence. Third and fourth heartsounds, if present, are both heard during diastole. S3 and S4 arelow-frequency soft sounds, which are best heard by applying thestethoscope softly on the skin or just firmly enough to create askin seal. It is easier to detect the S3 or the S4 by positioning thepatient in the left lateral position, which brings the heart closerto the heart wall. S3s and S4s are not affected by respirations andare heard as single sounds.

S3

S3 is heard early in diastole just after the S2 and is heard best inthe apex (see Figure 37–10 �). One cardiac cycle (S1, S2, S3,

sounds like lub-dub-dee or “Ken-tuc’-ky.” S3s are heard early indiastole because they are associated with abnormalities of ven-tricular filling, and they are sometimes called ventricular gal-lops. S3s are markers of systolic dysfunction. When there isventricular systolic dysfunction, the ventricle is not able toempty sufficiently with each systolic contraction. During eachconsecutive diastolic filling period, turbulence occurs as the“new” load of blood attempts to enter when the previous load ofblood has not completely left the ventricle.

An S3 heard over the left ventricle in children and youngadults is normal, although after ages 35 to 40, the presence of athird heart sound is usually abnormal and may indicate systolicdysfunction. An S3 and the presence of increased JVD are re-garded as specific signs of heart failure. The presence of an S3 inan older person may be the only clue to abnormal left ventricu-lar function (O’Connor, 1998).

S4

S4 occurs late in diastole just before the S1 and is heard best in theapex (Figure 37–10 �). One cardiac cycle (S4, S1, S2) sounds likedee-lub-dub or “Ten-nes-see.” S4s are heard late in diastole be-cause they are associated with the atrial kick component of dias-tole, and they are sometimes called atrial gallops. S4s are markersof diastolic dysfunction. An S4 occurs when the atria attempt topump blood into a stiff, noncompliant ventricle that is resistant tofurther volume expansion.

Diastolic dysfunction may occur with ventricular hypertrophyassociated with hypertension, with aortic stenosis, or with alteredventricular compliance associated with ischemia. Normal fourthheart sounds are common in older adults and are associated withan age-related decrease in left ventricular compliance (O’Connor,1998). A fourth heart sound is almost always abnormal in chil-dren and may contribute to a decrease in ventricular compliance.An S4 cannot be heard during atrial fibrillation,because S4s are as-sociated with atrial contraction against a noncompliant ventricle.

Summation GallopSummation gallops occur when both an S3 and an S4 are heard (S4,

S1, S2, S3) (see Figure 37–10 �); in other words, there is a combinedventricular and atrial gallop. A summation gallop is associatedwith advanced heart failure. The S3 and S4 may be heard as twodistinct sounds in diastole or, in the case of tachycardia, as a sin-gle mid-diastolic sound. Summation gallops are sometimes de-scribed as galloping hooves.

Pericardial Friction RubsPericardial friction rubs are due to inflammation of the pericar-dial sac surrounding the heart in conditions such as pericarditis.Pericarditis is described in detail in Chapter 41 . Pericardialfriction rubs are a transient high-pitched sound heard best at theleft sternal border. The sound that is produced is a squeaky, rub-bing, muffled sound. Pericardial friction rubs are heard best withthe patient leaning forward or lying on the left side. Pericardialfriction rubs may be a transient assessment finding.

Abnormal Heart Sounds: MurmursMurmurs are audible vibrations heard over the heart and greatvessels. Murmurs are caused by turbulent blood flow across adiseased valve (stenosis or regurgitation), turbulence caused byincreased blood flow through normal structures, or blood flowinto a dilated chamber (Chart 37–4). Whereas murmurs are aus-

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cultatory sounds caused by vibrations or turbulence in the heartand great vessels, bruits are auscultatory sounds associated withvibrations or turbulence in a blood vessel outside the heart.

Murmur EtiologyMurmurs are due to valve abnormalities of stenosis or regurgi-tation. Many different physiological conditions can lead to thesealterations. A stenotic valve is one whose valve leaflets are hard-ened, calcified, or narrowed. Blood flow is obstructed as it isforced through a narrowed, stenotic valve orifice. Valve regurgi-tation occurs when the valve leaflets fail to close completely. Thiscauses valve insufficiency, and a portion of the systolic bloodvolume is allowed to flow backward. Causes of abnormal valvesare discussed in Chapter 41 . As blood flows through thesetwo different types of valve alterations, the sounds generated arevery distinct. For example, blood flowing through a stenoticvalve would sound very harsh because blood is being forcedthrough a narrow opening, whereas blood flowing through a re-gurgitant valve would sound softer and have more of a gurglingquality. The sounds associated with particular valve disorders

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would be best heard at the corresponding valve’s auscultatorysite (Chart 37–5). When a murmur is auscultated, the etiologycan be suggested by understanding the physiology of the cardiaccycle and heart sounds. For example, during systole the aorticvalve is open, allowing blood to flow from the left ventriclethrough the aortic valve to the aorta, and the mitral valve isclosed, preventing blood from flowing back into the left atrium.If the aortic valve were stenotic, the sound would be a harshmurmur during systole over the aortic valve area. Likewise, if themitral valve were regurgitant, one would typically hear a gur-gling sound over the mitral valve area. During the assessmentthe nurse should evaluate for head bobbing up and down in syn-chrony with the heartbeat, because this is characteristic of severeaortic regurgitation (D’Amico & Barbarito, 2007).

Systolic murmurs, heard during systole, include mitral regur-gitation, tricuspid regurgitation, aortic stenosis, and pulmonicstenosis. Diastolic murmurs, heard during diastole, include mi-tral stenosis, tricuspid stenosis, aortic regurgitation, and pul-monic regurgitation.

Innocent MurmursSome murmurs may be classified as innocent or functionalmurmurs. An innocent murmur is a sound made by the bloodcirculating in the heart chambers or valves, or through the bloodvessels near the heart. Innocent murmurs are often soft and mayvary or disappear with position changes, whereas pathologicmurmurs are generally louder and seldom disappear with posi-tion changes. Innocent murmurs are harmless, asymptomatic,and are commonly heard in children. Further diagnostic testsmay be performed to rule out other conditions.

When a murmur is heard, it is important to describe thesound properly. Murmurs should be described in terms of theirtiming in the cardiac cycle, the auscultatory location they areheard best, frequency, intensity, radiation, and quality. A sum-mary of murmurs associated with valve disorders is presented inChart 37–6 (p. 970).

Gender Implications/Gender DifferencesBefore the 1980s, it was believed that cardiovascular disease (CVD)affected primarily men. This was due in large part to the fact thatmost research studies involved men. It is now well known thatwomen respond uniquely to CVD as well as to other diseases.Women experience the signs and symptoms associated with CVDdifferently than men. More women have asymptomatic and undi-agnosed CVD. It is difficult to apply preventive cardiovascular careto women who have not been identified as having CVD. Mortality

CHART 37–4 Classification of Murmurs

TIMING • Timing within the cardiac cycle.

• Systolic or diastolic (early, mid, late, continuous).

• Systolic murmurs are often benign.

• Diastolic murmurs are never benign.

LOCATION Auscultatory area the murmur is best heard.

• Aortic, pulmonic, mitral, tricuspid.

• Presence of murmurs at specific valve sites leads tothe identification of the affected valve.

FREQUENCY • High-pitched or low-pitched sound.

• Low-pitched murmurs are caused by a low velocity ofblood flow.

• High-pitched murmurs are caused by a rapid velocityof blood flow.

QUALITY • Descriptive quality of the sound.

• Harsh, rumbling, musical, soft, blowing, gurgling.

• Quality may indicate regurgitation or stenosis.

PATTERN • Configuration of sound if one were to draw it.

• Crescendo, decrescendo, diamond shaped.

RADIATION • Sounds may be radiated to the neck, back, shoulders,sternal border, jaw, arm, or left axilla.

• Some murmurs radiate in the direction of thebloodstream, by which they are produced.

INTENSITY Grading scale of loudness

• I/VI Very soft, barely audible.

• II/VI Soft, but loud enough to be appreciated.

• III/VI Loud, easily heard, no thrills or vibrations.

• IV/VI Loud, soft palpable thrill.

• V/VI Loud, heard with stethoscope barely touchingchest wall; palpable thrill.

• VI/VI Very loud, can be heard with stethoscope fullyoff chest wall, pronounced palpable thrill.

CHART 37–5 Valve Opening and Closing with Cardiac Cycle

OPEN CLOSED Abnormality

SYSTOLE Pulmonic Aortic(stenosis)

Tricuspid Mitral(regurgitation)

Regurgitationis unable tocompletelyclose

DIASTOLE Tricuspid Mitral(stenosis)

Pulmonic Aortic(regurgitation)

Stenosis isunable tocompletelyopen

GENETIC CONSIDERATIONSfor Cardiovascular Disease

A great deal is known about the independent risk factors for thedevelopment of cardiovascular disease. Advances made in the area ofgenetics since the Human Genome Project in 1988 have helpedscientists understand the genetic causes of cardiovascular disease. Ithas become clear that most cardiovascular diseases result fromvarious genetic causes (Allen, 2000). Gene mutations and theinteraction of genes and the environment are currently beingexamined. For example, polygenic disorders, such as hypertension,are caused by the combined effect of more than one mutated gene.Interestingly, the nature and severity of polygenic disorders varysignificantly and are unpredictable in nature (Allen, 2000).

Coronary artery disease is an example of a multifactorial disorder.Multifactorial disorders may have a genetic component, but thepresentation is largely affected by environmental factors. Forexample, multifactorial disorders may include an interaction ofgenetic factors (genetic abnormalities that result in lipid disorders,hypertension, and obesity) with nongenetic factors such as smoking,increasing age, and physical activity.

Through a thorough cardiovascular assessment, and potentiallyfuture genetic testing, inherited cardiovascular diseases or thesusceptibility to diseases can be identified. The hope is that earlydetection and diagnosis will identify individuals at risk. Thenprevention or modulation of the effects can be undertaken by theimplementation of a treatment plan, education, and counseling. Thegoal of genetic testing would be to save lives through preventivetreatment and therapeutic interventions. Nurses can complete familyhistory assessments and initiate appropriate referrals for geneticcounseling.


CHART 37–6 Summary of Murmurs Associated with Valve Disorders

AORTIC STENOSIS1. Midsystolic, crescendo-decrescendo

2. Harsh

3. Usually heard best in the aortic area

4. Often heard widely over the chest

5. Often radiates to the carotid arteries

6. Loudness unrelated to severity

AORTIC REGURGITATION1. Present in early diastole

2. Decrescendo configuration

3. High-pitched blowing

4. Heard best with the patient leaning forward; often faint

5. Loudness along Left Lower Sternal Border (LLSB)

MITRAL STENOSIS1. Long, rumbling diastolic murmur

2. Low pitched

3. Heard best with bell

4. Localized to mitral area (apex)

5. Often accompanied by a diastolic thrill in the area

6. Crescendo occurs in late diastole

MITRAL REGURGITATION1. Pansystolic

2. Loudest in mitral area (apex)

3. Radiates to left axilla

4. Usually blowing in quality

5. Systolic thrill usually present in mitral area

INNOCENT MURMUR1. Short, soft, systolic

2. Normal S1 and S2

3. Normal ECG and chest x-ray

4. Crescendo-decrescendo

5. Heard in primary aortic area

rates of CVD, particularly from sudden death, are currently higherin women than in men (D’Amore and Mora, 2006). D’Amore andMora (2006) suggest that women previously deemed at intermedi-ate risk for the development of CVD from standard availableguidelines, but who have concerning features in their medical his-tory such as a strong family history, may benefit from stress testing,which may provide further gender-specific prognostic informa-tion. Further studies are needed to identify gender-specific predic-tors of cardiac disease, and more comprehensive approaches toCVD prevention and treatment are needed for women. Although,many of the gender-specific differences in CVD are not well ex-plained, it is well understood that postmenopausal women are atgreater risk of developing CVD than are premenopausal women.

This is due to the cardioprotective effect of estrogen in pre-menopausal women. (Genetic predispositions to cardiovasculardisease are discussed in the Genetic Considerations box.)

Gerontological ConsiderationsThe number of elderly people over age 65 in the population ofthe United States has been steadily increasing. Therefore, itstands to reason that the number of elderly patients cared forin health care settings will also increase. The gerontologicalpopulation has unique considerations, which are important incardiovascular assessment. Physiological changes associatedwith aging include myocardial hypertrophy; an increase in col-lagen and scarring; a decrease in elasticity; fibrotic and scle-rotic changes of the atria and ventricles; calcification, sclerosis,or fibrosis of the cardiac valves; and rigidity and fibrosis of thevessels of the arterial system. These changes can lead to a dropin cardiac output, systolic or diastolic murmurs, increased fre-quency of dysrhythmias, and altered blood flow dynamics, allof which affect tissue perfusion. For example, elderly personsmay have elevations in systolic or diastolic blood pressures.Additionally, in the response to injury or shock, the heart be-comes less able to respond or initiate the stimulation of cate-cholamines needed to increase heart rate and contractility(Whetstone & Boswell, 2002). It is not uncommon to hear anS4 in an elderly person due to decreased compliance of the leftventricle or a systolic murmur due to aortic or mitral valve ab-normalities. Thickened myocardial fibers can also affect theconduction system of the heart and cause cardiac irritabilityand dysrhythmias. Diseases affecting other body systems can


affect the heart and blood vessels. Diabetes mellitus is one ex-ample of a disease that can have damaging effects on the pe-ripheral vasculature, and another is chronic obstructive lungdisease, which contributes to right-sided heart failure.

Normal physiological changes in the elderly can contribute tothe significance of cardiovascular signs and symptoms. For exam-ple, loss of muscle mass is a normal physiological change but cancontribute to symptoms of weakness of fatigue. It is essential toencourage a healthy diet and regular exercise program. The geron-tological population is more susceptible to cognitive impairmentsthat make them more vulnerable to the effects of cardiac diseasesand their treatments (Garrett, 1997). Dementia and deleriumare common cognitive impairments found in the geriatric pop-ulation. Cognitive losses of dementia affect the overall ability ofan individual to interact successfully with the environment. Theway the individual responds to stimuli from touch or stimuli fromthe environment may vary among individuals and should be con-sidered prior to the exam (Garrett, 1997). The nurse needs to un-derstand that there may be limitations in the patient’s abilities tolearn and apply new knowledge. It will be much more difficult forthe individual who is cognitively impaired to manage the com-plexities of his cardiovascular disease and its treatment. Changesin cerebral perfusion due to atherosclerosis may also be present.When cognitive impairments such as dementia or delerium aresuspected, the ability to provide accurate information for thehealth history will be altered (Garrett, 1997).

Critical Thinking Related toCardiovascular Assessment

Critical thinking is essential in order to prioritize the most sig-nificant clinical manifestations that need further investigation.Cardiovascular clinical manifestations can range from condi-tions as benign as an innocent murmur to life-threatening dis-orders such as heart failure. It is imperative that the nurse be ableto distinguish normal from abnormal, benign from serious. Thenurse must rely on critical thinking skills in interpreting the pa-tient’s symptoms and assessment findings to determine possibleand potential patient diagnoses and to consider the appropriateactions to take. Analysis of these data allows the nurse to make adiagnosis and then follow up with an intervention. It is impera-tive that the nurse communicate and collaborate with othermembers of the health care team in developing and implement-ing a plan of care.

Because cardiac disease manifestations can mimic other ab-normalities such as pulmonary disease, the nurse must questioneach symptom and then compare and contrast symptoms. Forexample, when the patient reports a sudden onset of chest pain,the nurse must possess knowledge of the difference in manifes-tations between the causes of cardiac versus pulmonary chestpain and assess the patient for each of them. Making an assump-tion that the pain is cardiac in nature would be inappropriateand shortsighted. Effective critical thinking skills include beingcurious and not making any assumptions. Regardless of thehealth problem, each symptom identified should be thoroughlydescribed in order for the nurse to gain a full understanding. Thenurse can say to the patient, “Tell me more about the problem,”or “How did it start?” The patient usually proceeds with a dis-

course about the symptoms. The nurse uses skillful interviewtechniques to explore and investigate each symptom further.Any symptom analysis would be incomplete without a thoroughdescription of its characteristics.

Implications for Health PromotionA good time to discuss the concept of health promotion with apatient is during a cardiovascular exam. Assessment can be a timeto review current health status, examine problem areas, identifyrisk factors that need to be modified, identify possible healthgoals, discuss options, and potentially develop a plan of care.During a health assessment nurses need to provide health educa-tion and supply the patient with educational materials. Nurses arein a unique position to help patients recognize health problemsor potential health problems. When abnormalities or positivefindings are discovered during the health history process, an op-portunity exists to discuss the issue in greater detail. Nursesshould also recognize their role in promoting healthy lifestylesand their abilities to empower a patient and her family to makeneeded changes in their lives. Be aware that certain health topicsare very personal, and some nurses have difficulty discussingthese sensitive issues with patients.

As the populations that are served in health care settingscontinue to change and nurses are caring for more diverse pop-ulations, they need to be knowledgeable about the health prac-tices of other cultures. Integrating culturally competent careincludes incorporation of complementary therapies into theplan of care that will ultimately help nurses accomplish the goalof health promotion for all patients.

Cardiovascular MonitoringCardiovascular monitoring is an integral part of nursing man-agement and includes many technologies used to augment thephysical exam. Monitoring devices range from simple noninva-sive monitoring, including assessment of heart rate, blood pres-sure, and pulse oximetry, to more invasive monitoring, such ashemodynamic monitoring using indwelling pulmonary arterycatheters and arterial catheters. Chapter 24 includes a com-plete discussion of invasive hemodynamic monitoring. The goalof cardiovascular monitoring is to obtain the data needed tocomplete the cardiovascular assessment in a timely fashion, inthe safest, most cost-efficient manner.

Assessment of Heart RateCounting the number of pulsations of the heart per minute de-termines heart rate. Assessment of heart rate should be per-formed when the patient is at rest in a calm environment. Manyfactors can alter the heart rate. For example, exercise, pain, andanxiety can cause an increase in circulating catecholamines,which may elevate heart rate and blood pressure. Endocrine andmetabolic conditions can also affect the heart rate. The heartnormally beats 60 to 100 times per minute. Heart rates less than60 beats per minute (bradycardia) may be caused by hypoxia,parasympathetic stimulation, or beta-adrenergic blocker med-ication (Docherty, 2002a), although many well-conditionedathletes have resting heart rates well below 60 beats per minute.Bradycardia may not be clinically significant, unless accompa-

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nied by systolic blood pressure of less than 90 mmHg, whichwould indicate that the slow rate is compromising cardiovascu-lar function (Docherty, 2002).

Heart rates over 100 beats per minute are termed tachycardia,and some causes are exercise, pyrexia, hypovolemia, anxiety, andpain. Other clinical conditions that increase oxygen demand,such as myocardial ischemia or respiratory distress, may alsocause tachycardia (Docherty, 2002a). Tachycardia can compro-mise cardiovascular status by decreasing diastolic filling timeand increasing oxygen consumption, which may cause a reduc-tion in stroke volume and eventually a drop in cardiac output.The regularity of the pulse should also be assessed. Irregularitiessuggest an alteration in cardiac conduction and should be fur-ther evaluated. Electrocardiogram (ECG) monitoring is a non-invasive method used to assess the heart rate and rhythm, and iscommonly utilized in acute care settings. Interpretation andanalysis of the ECG is discussed in Chapter 38 .

Assessment of Blood PressureArterial blood pressure (BP) is a measure of the pressure exertedby blood against the walls of the arterial system as it is ejectedfrom the left ventricle. Blood pressure is a dynamic, multidi-mensional indicator of a person’s cardiovascular state (Thomas,Liehr, DeKeyser, Frazier, & Friedmann, 2002). Assessment ofblood pressure reflects the events of the pulsatile cardiac cycleand is expressed as systolic/diastolic. The systolic blood pressure(SBP) is the peak pressure exerted against the arteries when theheart ventricles contract during systole. The diastolic bloodpressure (DBP) is the residual pressure existing in the arterialsystem at the end of diastole when the ventricles are relaxed andare filling with blood from the atria.

The recording of blood pressure can provide important in-formation about blood volume, cardiac output, and peripheralresistance. It is a critical component of vital signs and thereforeis a basic parameter for nurses’ physical assessments (Thomas etal., 2002). When the systolic and diastolic blood pressures are el-evated, so is the risk of developing cardiovascular disorders.High blood pressure causes the heart to work harder and directlydamages the smooth muscle that lines the cardiovascular system(see Chapter 21 and Chapter 40 ). Hypertension must betreated promptly to prevent complications such as the develop-ment of atherosclerotic cardiovascular disease, myocardial in-farction, and stroke.

Blood pressure can be measured in several ways: either indi-rectly by use of auscultatory methods such as mercury columnor aneroid (clock-face) sphygmomanometers or by use of oscil-latory methods such as the electronic automatic blood pressurecuffs that produce a digital readout, or directly by use of invasivemonitoring devices.

In many clinic and hospital settings the most common wayto obtain blood pressure recordings is by auscultation with theuse of an indirect sphygmomanometer. Pressure is exerted onthe main artery of the arm by the inflated blood pressure cuff.The stethoscope is used to listen for Korotkoff ’s sounds, whichchange in tone and volume as the cuff is deflated and blood flowis gradually restarted. The first sound heard is the systolic bloodpressure, which represents the highest blood pressure that oc-curs each time the heart beats. The second recording is the dias-

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tolic blood pressure, which represents the lowest blood pressurethat occurs when the heart relaxes between beats.

Accuracy in the measurement of BP is imperative becausethese data often guide medical and nursing practice. Many ther-apeutic decisions are made based on BP recordings. Althoughthe skill of measuring blood pressure appears simple, there aremany possible causes of errors and inaccuracies (Chart 37–7).Inaccuracies in BP assessment can lead to underestimation oroverestimation of blood pressure, causing errors in the diagno-sis and treatment of cardiovascular conditions. The AmericanHeart Association has published standard recommendationsand a step-by-step protocol for the indirect measurement ofblood pressure (Chart 37–8). Guidelines provide a consistent,uniform technique for measuring blood pressure. However,nurses should be periodically retrained in determination ofblood pressure. Retraining of blood pressure observers has beenshown to reduce variability of blood pressure due to human er-ror (Jones, Apperl, Sheps, Roccella, & Lenfant, 2003).

It is important for nurses to understand that the BP in an ar-tery is a dynamic number and changes throughout the day. It isthe lowest during sleep. It rises on waking and can rise with ex-citation, nervousness, or activity. Therefore, a single reading ofhigh blood pressure is not used to make a diagnosis of hyperten-sion. Treatment of hypertension includes lifestyle managementincluding dietary changes and exercise as well as a variety ofmedications (angiotensin converting enzyme inhibitors, an-giotensin receptor blockers, beta-blockers, calcium channelblockers). Chapter 21 contains an in-depth discussion of hy-pertension guidelines and treatment.

Classification of Blood PressureThe National Heart, Lung, and Blood Institute (NHLBI) hasclassified two levels of high blood pressure. A blood pressurereading below 120/80 mmHg is considered normal. Blood pres-

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CHART 37–7 Inaccuracies in Measurement of Blood Pressure

Inaccuracies in measurement of blood pressure are common clinicalproblems and can occur due to human error or device error for numerousreasons:

Inappropriately sized cuffs (too wide or too narrow)

Incorrect cuff positioning

Incorrect cuff wrapping (too loose or uneven)

Failure to allow a rest period before measurement

Deflating the cuff too quickly or too slowly

Inaccurate inflation level

Not measuring in both arms

Failure to palpate maximal systolic pressure before auscultation

Improper position of the arm (above or below heart level)

Poor observer concentration

Lack of repeated measurements

Poorly fitting stethoscope.

Sources: Jones, D. W., Apperl, L. J., Sheps, S. G., Roccella, E. J., & Lenfant, C. (2003).Measuring blood pressure accurately: New and persistent challenges. JAMA, 289(8),1027–1030; McAlister, F. A., & Straus, S. E. (2001). Measurement of blood pressure: Anevidenced based review. British Medical Journal, 322(7291), 908–911.


sures under 140/90 mmHg are classified as either normal or pre-hypertension. Prehypertension is systolic blood pressures be-tween 120 and 137, or diastolic readings between 80 and 89.Hypertension is considered when the blood pressure reading in140/90 mmHg. These classifications are for adults over age 18who are not on medicine for high blood pressure, are not hav-ing a short-term serious illness, and do not have other condi-tions such as diabetes or kidney disease. An exception to thisclassification is that a blood pressure of 130/80 mmHg or higheris considered high blood pressure in persons with diabetes andchronic kidney disease (NHLBI, 2008). Classifications, preven-

tion, and management of hypertension are discussed in detail inChapter 21 .

Health Promotion: Preventing HypertensionThe National High Blood Pressure Education Program(NHBPEP), established in 1972, is a cooperative effortamong professional and voluntary health agencies, statehealth departments, and many community groups. TheNHBPEP is administered and coordinated by the NationalHeart, Lung, and Blood Institute (NHLBI). The goal of theNHBPEP is to reduce death and disability related to high

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CHART 37–8 Technique for Measurement of Blood Pressure

The intent and purpose of the measurement should be explained to the subject in a reassuring manner, and every effort should be made to put the subjectat ease.

The sequential steps for measuring the blood pressure in the upper extremity, as for routine screening and monitoring purposes, should include thefollowing:

1. Have paper and pen at hand for immediate recording of the pressure.

2. Seat the subject in a quiet, calm environment with her bared arm resting on a standard table or other support so the midpoint of the upper arm is atthe level of the heart.

3. Estimate by inspection or measure with a tape the circumference of the bare upper arm at the midpoint between the acromion and olecranonprocess (between the shoulder and elbow), and select an appropriately sized cuff. The bladder inside the cuff should encircle 80% of the arm inadults and 100% of the arm in children under 13 years old. If in doubt, use a larger cuff. If the available cuff is too small, this should be noted.

4. Palpate the brachial artery and place the cuff so that the midline of the bladder is over the arterial pulsation; then wrap and secure the cuff snuglyaround the subject’s bare upper arm. Avoid rolling up the sleeve in such a manner that it forms a tight tourniquet around the upper arm. Looseapplication of the cuff results in overestimation of the pressure. The lower edge of the cuff should be 1 inch (2 centimeters) above the antecubitalfossa (bend of the elbow), where the head of the stethoscope is to be placed.

5. Place the manometer so that the center of the mercury column or aneroid dial is at eye level and easily visible to the observer, and the tubing fromthe cuff is unobstructed.

6. Inflate the cuff rapidly to 70 mmHg, and increase by 10 mmHg increments while palpating the radial pulse. Note the level of pressure at which thepulse disappears and subsequently reappears during deflation. This procedure, the palpatory method, provides a necessary preliminaryapproximation of the systolic blood pressure to ensure an adequate level of inflation when the actual, auscultatory measurement is made. Thepalpatory method is particularly useful to avoid underinflation of the cuff in patients with an auscultatory gap and overinflation in those with verylow blood pressure.

7. Place the earpieces of the stethoscope into the ear canals, angled forward to fit snugly. Switch the stethoscope head to the low-frequency position(bell). The setting can be confirmed by listening as the stethoscope head is tapped gently.

8. Place the head of the stethoscope over the brachial artery pulsation, just above and medial to the antecubital fossa but below the lower edge of thecuff, and hold it firmly in place, making sure that the head makes contact with the skin around its entire circumference. Wedging the head of thestethoscope under the edge of the cuff may free up one hand but results in considerable extraneous noise.

9. Inflate the bladder rapidly and steadily to a pressure 20 to 30 mmHg above the level previously determined by palpation, and then partially unscrew(open) the valve and deflate the bladder at 2 mm/s while listening for the appearance of the Korotkoff’s sounds.

10. As the pressure in the bladder falls, note the level of the pressure on the manometer at the first appearance of repetitive sounds (Phase I), at themuffling of these sounds (Phase IV), and when they disappear (Phase V). During the period the Korotkoff’s sounds are audible, the rate of deflationshould be no more than 2 millimeters per pulse beat, thereby compensating for both rapid and slow heart rates.

11. After the last Korotkoff’s sound is heard, the cuff should be deflated slowly for at least another 10 mmHg, to ensure that no further sounds areaudible, and then rapidly and completely deflated. The subject should be allowed to rest for at least 30 seconds.

12. The systolic (Phase I) and diastolic (Phase V) pressures should be immediately recorded, rounded off (upward) to the nearest 2 mmHg. In children,and when sounds are heard nearly to a level of 0 mmHg, the Phase IV pressure should also be recorded. All values should be recorded together withthe name of the subject, the date and time of the measurement, the arm on which the measurement was made, the subject’s position, and the cuffsize (when a nonstandard size is used).

13. The measurement should be repeated after at least 30 seconds, and the two readings averaged. In clinical situations additional measurements canbe made in the same or opposite arm, and in the same or an alternative position.

Source: Perloff, D., Grim, C., Flack, J., Frohlich, E., Hill, M., McDonald, M., et al. (Writing Group). (1993). Human blood pressure determination by sphygmomanometry (American Heart Association,Product Code: 2460-2467). Dallas, TX: American Heart Association.


FIGURE 37–10 � Pulse oximeter.

blood pressure through programs of professional, patient,and public education. Another goal of the NHBPEP is toachieve the Healthy People 2010 heart disease and stroke ob-jectives for the nation (DHHS, 2004). Strategies to meet theprogram’s goal include developing and disseminating sci-ence-based-educational materials and developing partner-ships among the program participants.

Assessment of Oxygen DeliveryPulse oximetry allows noninvasive estimation of hemoglobinoxygen saturation, or SpO2, which is the amount of hemoglo-bin saturated with oxygen (Figure 37–10 �). These deviceswork by using a light sensor containing two sources of light(red and infrared) that are absorbed by hemoglobin and thentransmitted through the tissue to a photodetector. The amountof light transmitted through the tissue is converted to a digitalvalue, which represents the percentage of hemoglobin satu-rated with oxygen (Lynn-McHale & Carlson, 2005).

Normal oxygen saturation values are 97% to 99% in a healthyindividual, but a value of 95% is clinically acceptable in a patientwith a normal hemoglobin level (Lynn-McHale & Carlson,2005). It should be reinforced that tissue oxygenation is not re-flected by oxygen saturation because the affinity of hemoglobinto oxygen may actually either impair or enhance the way oxygenis released at the tissue level. Additionally, oxygen saturationdoes not reflect a patient’s ability to ventilate, and thus its clini-cal use is limited in patients with obstructive pulmonary disease(Lynn-McHale & Carlson, 2005). SpO2 values, however, are of-ten monitored to allow for observations of trends and changesover time. For example, in a patient with emphysema, an SpO2

of 93% might be considered a normal baseline. If however, hehad an exacerbation of symptoms and his SpO2 dropped to 90%or lower, the finding would be significant and reportable.

Oxygen saturation can be measured from several sites, in-cluding fingers, toes, and earlobes. It is important to rememberthat some situations—such as low perfusion, low temperature,anemia, discoloration of the nail bed, and even carbon monox-ide poisoning,—will affect the ability of the sensor to estimatevenous oxygen saturation accurately. The device should not beused on the same extremity as a blood pressure cuff, which mayinterrupt blood supply (Docherty, 2002b). The accuracy of themeasurement is dependent on peripheral circulation, whichmay be compromised in a critically ill adult. Pulse oximetry, asa simple, noninvasive monitoring device, can be used continu-ously to assess adequacy of oxygen delivery. It may also be em-ployed as a substitute for frequent arterial blood gas analysis,which involves needlesticks to obtain arterial blood (Docherty,2002b). Therefore, pulse oximetry is efficient in that it can savenursing time, cost, and patient discomfort.

SummaryA thorough and accurate cardiovascular assessment is an im-portant nursing tool. Findings from cardiovascular assessmentscan lead to early identification of potentially life-threateningconditions and provide an opportunity for timely application of

preventative measures and treatment modalities. Cardiovascu-lar assessment skills are mandatory in acute care as well as inmany other nursing settings. Experience with cardiovascular as-sessment allows a nurse to validate and interpret findings in or-der to implement appropriate therapeutic interventions. Nursesmay implement preventative strategies, initiate treatment plans,or provide education or counseling.


NCLEX® REVIEW1. The nurse determines a male patient with hypertension and

hypertriglyceridemia meets the criteria for metabolicsyndrome when the cardiovascular assessment demonstrateswhich finding?

1. Random blood sugar is 150mg/dL.

2. Waist circumference is 110 cm.

3. High density lipids, HDL’s, are 52mg/dL.

4. Fasting blood sugar is 100mg/dL.

2. When assessing the medication history of a patient withheart disease the nurse would be most concerned when thepatient reports frequent use of which medication?

1. Proton pump inhibitor

2. Antacids

3. Bulk forming laxatives

4. Decongestants

3. A patient in the reports having difficulty sleeping at nightsecondary to becoming short of breath when lying down. Inorder to further assess the degree of orthopnea, the nurseshould ask which question.

1. “How often do you wake up at night?”

2. “How many pillows do you sleep on?”

3. “Do you experience palpitations that awaken you?”

4. “How often do you get up to urinate during the night?”

4. When auscultating heart sounds the nurse hears a thirdheart sound and recognizes the patient has which condition?

1. Diastolic dysfunction

2. Systolic dysfunction

3. Conduction defect of the SA node

4. Dysfunctional mitral valve

Answers for review questions appear in Appendix 5

KEY TERMSabdominojugular reflux p.1063auscultation p.1065bruits p.1069cyanosis p.1062dyspnea p.1057

edema p.1058heaves p.1065jugular venous pressure (JVP) p.1062murmurs p.1068nocturia p.1057

orthopnea p.1057palpitations p.1057syncope p.1058thrills p.1065turgor p.1064

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