Chapter 17: Assessing the Cardiovascular
What You Will Learn
• How inspection, auscultation, and palpation are used to assess
cardiac status in the elderly resident
Author: Key Terms
Carol Harrington RN, BC, ANP,
Carotid Pulse — Arterial pulse palpated over the carotid artery on the
CDE, Adult Nurse Practitioner,
Kansas City Internal Medicine, patient’s neck
Kansas City, MO Coronary Arteries — Blood vessels that supply blood directly to the heart
Cyanosis — Blue, gray, slate, or dark purple skin or mucous membrane
discoloration caused by deoxygenated or reduced blood hemoglobin
Dorsalis Pedis Pulse — Arterial pulse palpated on the dorsal aspect of
Femoral Pulse — Arterial pulse palpated in the groin/ femoral artery
Mediastinum — A septum or cavity between two principal portions of an
organ; the cavity between the two pleural sacs (and lungs) containing the
heart, great vessels, trachea, bronchi, esophagus, thymus gland, lymph
nodes, nerves, and other tissues.
Murmur — An unusual heart sound, which may or may not be innocent or
Pallor — Lack of color or paleness
Pericardium — Membranous, fibroserous sac enclosing the heart and the
bases of the great vessels
Popliteal Pulse — Arterial pulse palpated behind the knee over the
Posterior Tibial Pulse — Arterial pulse palpated behind the medial mal-
Radial Pulse — Arterial pulse palpated on the thumb side of the wrist
over the radial artery
Temporal Pulse — Arterial pulse palpated on either of the temporal areas
of the head
Thrombophlebitis — Inflammation of a vein in conjunction with the
formation of a thrombus (clot), usually occuring in the extremity, most
frequently the leg
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To perform an accurate assessment of the cardiovascular system, the
nurse must first have a working knowledge of the anatomy and physiology
of the structures.
The heart is a hollow muscular organ lying in the anterior chest (medi-
astinum) just above the diaphragm, to the left of the midline, cradled
between the lungs. The heart weighs approximately 300 grams (10.6 oz.).
The normal adult heart beats 60 to 80 beats per minute, ejecting approxi-
The normal adult heart beats 60 mately 70 mL from each side with each beat. The heart’s function is to
to 80 times per minute. pump the freshly oxygenated blood to the tissues of the body.
The right and left sides of the heart are separated by a muscular divider
called the septum. Each side of the heart is made of two chambers: an
atrium and a ventricle. The right side of the heart pumps entirely to lungs
via the pulmonary artery. The left side of the heart pumps to the rest of
the body via the aorta. The right and left side of the heart pump simulta-
neously. The atria receive blood from the veins, and the ventricles eject
blood into arteries.
Heart valves control the flow of blood in one direction through the heart.
The valves are composed of thin fibrous tissue and open and close in re-
sponse to pressure changes in the heart. Atrioventricular valves are those
separating the atria from the ventricles. The tricuspid valve, composed
of three leaflets, separates the right atrium and ventricle. The mitral or
bicuspid valve, composed of two leaflets, lies between the left atrium and
ventricle. Semilunar valves separate the ventricles from the arteries. These
include the pulmonic valve separating the right ventricle from the pul-
monary artery, and the aortic valve separating the left ventricle from the
aorta. The semilunar valves are composed of three cusps.
The pericardium is the thin fibrous sac encasing the heart. The space
between the pericardium and the heart is filled with a lubricating fluid to
reduce friction with the muscle’s contraction.
The coronary arteries supply required oxygen and nutrients to the heart
muscle. The heart has large metabolic requirements using half of the
delivered oxygen. In contrast, the other organs use approximately one
quarter of the delivered oxygen. The coronary arteries arise from the
aorta near its origin on the left ventricle. The left main coronary artery,
left anterior descending artery, and the left circumflex arteries supply
nutrients to the left side of the heart. The right coronary artery supplies
nutrients to the right wall of the heart.
Figure 17.1. Cardiovascular A systematic approach progressing from inspection to palpation and
System auscultation will ensure the examiner does not overlook obvious signs of
trouble. A complete set of vital signs should accompany this exam. Be-
fore beginning the exam, the nurse should ensure that the resident is in
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a relaxed position. An uncomfortable or anxious resident may have an
increased pulse rate, which may lead to misinterpretation of the findings.
Inspection and palpation are used simultaneously.
Begin the inspection portion of the cardiovascular exam with the resident
in a supine (lying down) position with his head slightly elevated. The room
should be well lit. During inspection, the examiner should visualize the
anterior chest. There is a normal impulse discrete and localized over the
apex of the heart that is easily visualized in older persons who are thin.
This is the apical pulse. It is usually located in the left fifth intercostal
space in the midclavicular line.
On inspection of the periphery (head and extremities), look for cyanosis
(blue color of skin); this implies diminished blood flow. Pallor (pale skin)
can be evidence of anemia. The resident’s hands should be warm and dry.
Under stress, they may be cool and moist, and with cardiogenic shock
cold and clammy. Edema makes the skin tight whereas dehydration and
aging create a loose feeling to the skin also called reduced skin turgor. In-
spect the lips and earlobes for cyanosis. Many residents with heart disease
have peripheral artery disease. Therefore, peripheral artery circulation
and venous return should be assessed. Those residents on bed rest or suf-
fering from immobility are at high risk for thrombophlebitis, so careful
monitoring through inspection of skin color, skin temperature, and hair
growth is essential.
Cool or cold extremities may be a After completing the inspection, move on to palpation. Palpate the apical
sign of decreased circulation or pulse by using the palm of one hand. Use two or three fingers to palpate
absence of blood flow. the temporal, carotid radial, femoral, popliteal, dorsalis pedis, and
posterior tibial pulses. Note the quality of pulse feeling for a bound-
ing, faint, or irregular pulse. Palpate the resident’s skin temperature. Cool
or cold extremities may be a sign of decreased circulation or absence of
blood flow. Palpate the skin for turgor and moisture. Very tight skin can
signal fluid retention and very loose skin may signal dehydration.
To assess edema, the examiner presses the index finger over the bony
Edema makes the skin tight prominence of the tibia (lower leg) or the medial malleolus (ankle) for a
whereas dehydration and aging few seconds. Pitting edema is a depression that does not rapidly refill or
create a loose feeling to the skin resume its original contour. Severity of edema is measured using a grad-
also called reduced skin turgor. ing system (1+ through 4+) as follows:
• 1+ pitting edema is 2mm or slight pitting with rapid recovery.
• 2+ is 4mm pitting with recovery in 10 to 15 seconds.
• 3+ is 6mm of pitting lasting greater than one minute.
• 4+ is 8mm pitting lasting two to five minutes.
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Always measure the severity of edema of both extremities. If edema is
unilateral, the examiner must suspect occlusion of a major vein such as
with deep vein thrombosis (DVT).
Remember that different problems with circulation can have different
causes. With arterial (supply) disease, the feet may be cool or even bluish
Edema is common in the nurs- at the toes. Any swelling indicates either local infection or possibly a ve-
ing home population as many are nous (return) blockage, or dependent edema from gravity. It is important
wheelchair bound causing depen- to note that the amount blood going “into” an extremity or organ is heav-
dent edema. ily determined by the amount getting “out.”
Closure of the heart valves creates heart sounds heard by auscultation.
In the normal heart, systole and diastole are silent. Abnormalities of the
heart valves causing them to be open when they should be closed gives
rise to heart murmurs. During auscultation, the room should be quiet
and the resident in a sitting or supine position. The right-handed exam-
iner should be on the resident’s right side, the left-handed examiner on
the resident’s left side. Using the diaphragm of the stethoscope, the ex-
aminer should listen at the left anterior chest for heart sounds. The nurse
auscultates for rate and rhythm. Irregular rhythms may be caused simply
by breathing or may indicate a condition such as atrial fibrillation. Each
combination of S1 and S2 (“lub-dub”) counts for one heart beat. The nurse
should follow a pattern when auscultating the left anterior chest start-
ing just above the medial breast on a female and above and medial to the
nipple on a male. Move the stethoscope systemically in a counterclock-
wise motion listening at 11, 9, 7, and 4 o’clock.
Gently lift the breast tissue of the female resident to better assess heart
sounds. The nurse must note extra heart sounds such as murmurs. Mur-
murs are sustained swishing sounds heard between the two heart sounds.
Murmurs can be a sign of a chronic valvular heart disease or a newly
found valve disorder. If the murmur is a new finding, it should be reported
to the health care provider for further evaluation.
In summary, the cardiac evaluation is a key part of the resident’s exami-
nation. Cardiovascular disease is the number one cause of death in the
elderly patient. Abnormal findings can be a sign of progression of chronic
disease or lead to the diagnosis of a newly diagnosed cardiac disease. The
nurse must carefully document cardiac findings in the resident’s chart and
report any new findings to the healthcare provider.
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Chapter 17 Review Questions
Define the following terms: Circle “True” or “False” as appropriate for the
1. Carotid Pulse —
15. (True/False) — Occasional skipped heart-
beats are common in the elderly resident.
2. Coronary Arteries —
Answer the following multiple-choice question:
3. Cyanosis —
16. Unilateral edema may be a sign of:
a. Arterial disease
4. Dorsalis Pedis Pulse —
c. Occlusion of a major vein
5. Femoral Pulse —
d. Poor skin turgor
6. Mediastinum — Complete the following:
17. The normal adult heart beat is ________ to
7. Murmur — __________beats per minute.
18. The __________________ of a pulse is rated as
8. Pallor — bounding, normal, diminished, or absent.
19. A cool or cold extremity can be a sign of:
9. Pericardium — a.
10. Popliteal Pulse — b.
11. Posterior Tibial Pulse —
12. Radial Pulse —
13. Temporal Pulse —
14. Thrombophlebitis —
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