Assessment
HEALTH HISTORY
To obtain a health history of a patient’s cardiovascular system, begin by introducing yourself and explaining what will occur during the health history interview and physical examination. To take an effective history, establish rapport with the patient. Ask open-ended questions and listen carefully to responses. Closely observe the patient’s nonverbal behavior.
Chief complaint
A patient with a cardiovascular problem typically cites specific complaints, such as:
chest pain
irregular heartbeat or palpitations
shortness of breath on exertion, lying down, or at night
cough
cyanosis or pallor
weakness
fatigue
unexplained weight change
swelling of the extremities
dizziness
headache
high or low blood pressure
peripheral skin changes, such as decreased hair distribution, skin color changes, or a thin, shiny appearance to the skin
pain in the extremities, such as leg pain or cramps.
Ask the patient how long he has had the problem, how it affects his daily routine, and when it began. Find out about any associated
signs and symptoms. Ask about the location, radiation, intensity, and duration of any pain and any precipitating, exacerbating, or relieving factors. Ask him to rate the pain on a scale of 1 to 10, in which 1 means negligible and 10 means the worst pain imaginable.
signs and symptoms. Ask about the location, radiation, intensity, and duration of any pain and any precipitating, exacerbating, or relieving factors. Ask him to rate the pain on a scale of 1 to 10, in which 1 means negligible and 10 means the worst pain imaginable.
Let the patient describe his problem in his own words. Avoid leading questions. Use expressions familiar to him rather than medical terms whenever possible. If the patient isn’t in distress, ask questions that require more than a yes-or-no response. Try to obtain as accurate a description as possible of any chest pain.
AGE AWAREEven a child old enough to talk may have difficulty describing chest pain, so be alert for nonverbal clues, such as restlessness, facial grimaces, or holding of the painful area. Ask the child to point to the painful area and then to show you with his finger where the pain goes (to find out if it’s radiating). Determine the pain’s severity by asking the parents if the pain interferes with the child’s normal activities and behavior. Because an elderly patient has a higher risk of developing life-threatening conditions, such as a myocardial infarction (MI), angina, and aortic dissection, carefully evaluate chest pain.
Current health history
In addition to checking for pain, ask the patient these questions:
Are you ever short of breath? If so, what activities cause you to be short of breath?
Do you feel dizzy or fatigued?
Do your rings or shoes feel tight?
Do your ankles swell?
Have you noticed changes in the color or sensation in your legs? If so, what are those changes?
If you have sores or ulcers, how quickly do they heal?
Do you stand or sit in one place for long periods at work?
How many pillows do you sleep on at night? (See Key questions for assessing cardiac function, page 26.)
Orthopnea or dyspnea that occurs when the patient is lying down and improves when he sits up suggests left ventricular heart failure or mitral stenosis. It can also accompany obstructive lung disease.
Pregnant women, especially those in the third trimester or those who stand for long periods of time, may report ankle edema. This is a common discomfort of pregnancy.
Past health history
Ask the patient about any history of cardiac-related disorders, such as hypertension, rheumatic fever, scarlet fever, diabetes mellitus, hyperlipidemia,
congenital heart defects, and syncope. Other questions to ask include:
congenital heart defects, and syncope. Other questions to ask include:
KEY QUESTIONS FOR ASSESSING CARDIAC FUNCTION
These questions and statements will help you to assess your patient’s cardiac function more accurately:
Are you still in pain? Where’s it located? Point to where you feel it.
Describe what the pain feels like. (If the patient needs prompting, ask if he feels a burning, tightness, or squeezing sensation in his chest.)
Does the pain radiate to any other part of your body? Your arm? Neck? Back? Jaw?
When did the pain begin? What relieves it? What makes it feel worse?
Tell me about any other feelings you’re experiencing. (If the patient needs prompting, suggest nausea, dizziness, or sweating.)
Tell me about any feelings of shortness of breath. Does a particular body position seem to bring this on? Which one? How long does the shortness of breath last? What relieves it?
Has sudden breathing trouble ever awakened you from sleep? Tell me more about this.
Do you ever wake up coughing? How often? Have you ever coughed up blood?
Does your heart ever pound or skip a beat? If so, when does this happen?
Do you ever get dizzy or faint? What seems to bring this on?
Tell me about any swelling in your ankles or feet. At what time of day? Does anything relieve the swelling?
Do you urinate more frequently at night?
Tell me how you feel while you’re doing your daily activities. Have you had to limit your activities or rest more often while doing them?
Have you ever had severe fatigue not caused by exertion?
Are you taking any prescription, over-the-counter, or illicit drugs?
Are you allergic to any drugs, foods, or other products? If yes, describe the reaction you experienced.
In addition, ask a woman:
Have you begun menopause?
Do you use hormonal contraceptives or estrogen?
Have you experienced any medical problems during pregnancy? Have you ever had gestational hypertension?
Family history
Information about the patient’s blood relatives may suggest a specific cardiac problem. Ask him if anyone in his family has ever had hypertension,
MI, cardiomyopathy, diabetes mellitus, coronary artery disease (CAD), vascular disease, hyperlipidemia, or sudden death.
MI, cardiomyopathy, diabetes mellitus, coronary artery disease (CAD), vascular disease, hyperlipidemia, or sudden death.
As you analyze a patient’s problems, remember that age, gender, and race are essential considerations in identifying the risk for cardiovascular disorders. For example, CAD most commonly affects white men between ages 40 and 60. Hypertension occurs most commonly in blacks. Women are also vulnerable to heart disease, especially post-menopausal women and those with diabetes mellitus.
AGE AWAREMany elderly people have increased systolic blood pressure because aging increases the rigidity of blood vessel walls. Overall, elderly people have a higher incidence of cardiovascular disease than younger people.
Psychosocial history
Obtain information about your patient’s occupation, educational background, living arrangements, daily activities, and family relationships.
Also obtain information about:
stress and how he deals with it
current health habits, such as smoking, alcohol intake, caffeine intake, exercise, and dietary intake of fat and sodium
environmental or occupational considerations
activities of daily living.
During the history-taking session, note the appropriateness of the patient’s responses, his speech clarity, and his mood to aid in better identifying changes later.
PHYSICAL ASSESSMENT
Cardiovascular disease affects people of all ages and can take many forms. Using a consistent, methodical approach to your assessment will help you identify abnormalities. The key to accurate assessment is regular practice, which will help improve technique and efficiency.
Before assessing the patient’s cardiovascular system, assess the factors that reflect cardiovascular function. These include vital signs, general appearance, and related body structures.
Wash your hands and gather the necessary equipment. Choose a private room. Adjust the thermostat, if necessary; cool temperatures may alter the patient’s skin temperature and color, heart rate, and blood pressure. Make sure the room is quiet. If possible, close the door and windows and turn off radios and noisy equipment.
Combine parts of the physical assessment, as needed, to conserve time and the patient’s energy. If a female patient feels embarrassed
about exposing her chest, explain each assessment step beforehand, use drapes appropriately, and expose only the area being assessed. If the patient experiences cardiovascular difficulties, alter the order of the assessment as needed.
about exposing her chest, explain each assessment step beforehand, use drapes appropriately, and expose only the area being assessed. If the patient experiences cardiovascular difficulties, alter the order of the assessment as needed.
RED FLAGIf the patient develops chest pain and dyspnea, quickly check his vital signs and then auscultate the heart.
Vital sign assessment
Assessing vital signs includes measurement of temperature, blood pressure, pulse rate, and respiratory rate.
TEMPERATURE MEASUREMENT
Temperature is measured and documented in degrees Fahrenheit (° F) or degrees Celsius (° C). Choose the method of obtaining the patient’s temperature (oral, tympanic, rectal, or axillary) based on the patient’s age and condition. Normal body temperature ranges from 96.8° F to 99.5° F (36° C to 37.5° C).
If the patient has a fever, anticipate these possibilities:
cardiovascular inflammation or infection
heightened cardiac workload (Assess a febrile patient with heart disease for signs of increased cardiac workload such as tachycardia.)
MI or acute pericarditis (mild to moderate fever usually occurs 2 to 5 days after an MI when the healing infarct passes through the inflammatory stage)
infections, such as infective endocarditis, which causes fever spikes (high fever).
In patients with lower than normal body temperatures, findings include poor perfusion and certain metabolic disorders.
BLOOD PRESSURE MEASUREMENT
First, palpate and then auscultate the blood pressure in an arm or a leg. Wait 5 minutes between measurements. Normally, blood pressure readings are less than 120/80 mm Hg in a resting adult and 78/46 to 114/78 mm Hg in a young child. (See Measuring blood pressure accurately.)
Emotional stress caused by physical examination may elevate blood pressure. If the patient’s blood pressure is high, allow him to relax for several minutes and then measure again to rule out stress.
When assessing a patient’s blood pressure for the first time, take measurements in both arms.
RED FLAGA difference of 10 mm Hg or more between the patient’s arms can indicate thoracic outlet syndrome or another form of arterial obstruction.
MEASURING BLOOD PRESSURE ACCURATELY
When taking the patient’s blood pressure, begin by applying the cuff properly, as shown below. Then be alert for these common problems to avoid recording an inaccurate blood pressure measurement.
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Wrong-sized cuff. Select the appropriate-sized cuff for the patient. This ensures that adequate pressure is applied to compress the brachial artery during cuff inflation. If the cuff bladder is too narrow, a false-high reading will be obtained; too wide, a false-low reading. The cuff bladder width should be about 40% of the circumference of the midpoint of the limb; bladder length should be twice the width. If the arm circumference is less than 13″ (33 cm), select a regularsized cuff; if it’s between 13″ and 16″ (33 to 40.5 cm), a large-sized cuff; if it’s more than 16″, a thigh cuff. Pediatric cuffs are also available.
Slow cuff deflation, causing venous congestion. Don’t deflate the cuff more slowly than 2 mm Hg/heartbeat; you’ll get a false-high reading.
Cuff wrapped too loosely, reducing its effective width. Tighten the cuff to avoid a false-high reading.
Mercury column not read at eye level. Read the mercury column at eye level. If the column is below eye level, you may record a false-low reading; if it’s above eye level, a false-high reading.
Poorly timed measurement. Don’t take the patient’s blood pressure if he appears anxious or has just eaten or been ambulating; you’ll get a false-high reading.
Incorrect position of the arm. Keep the patient’s arm level with his heart to avoid a false-low reading.
Failure to notice an auscultatory gap (sound fades out for 10 to 15 mm Hg then returns). To avoid missing the top Korotkoff sounds, stimulate systolic pressure by palpation first.
Inaudibility of feeble sounds. Before reinflating the cuff, have the patient raise his arm to reduce venous pressure and amplify low-volume sounds. After inflating the cuff, lower the patient’s arm; then deflate the cuff and listen. Or, with the patient’s arm positioned at heart level, inflate the cuff and have the patient make a fist. Have him rapidly open and close his hand 10 times before you begin to deflate the cuff; then listen. Be sure to document that the blood pressure reading was augmented.
If blood pressure is elevated in both arms, measure the pressure in the thigh. Wrap a large cuff around the patient’s upper leg at least 1″ (2.5 cm) above the knee. Place the stethoscope over the popliteal artery, located on the posterior surface slightly above the knee joint. Listen for sounds when the bladder of the cuff is deflated.
High blood pressure in the patient’s arms with normal or low pressure in the legs suggests aortic coarctation.
PULSE PRESSURE DETERMINATION
To calculate the patient’s pulse pressure, subtract the diastolic pressure from the systolic pressure. This reflects arterial pressure during the resting phase of the cardiac cycle and normally ranges from 30 to 50 mm Hg.
Rising pulse pressure is seen with:
increased stroke volume, which occurs with exercise, anxiety, and bradycardia
declined peripheral vascular resistance or aortic distention, which occurs with anemia, hyperthyroidism, fever, hypertension, aortic coarctation, and aging.
Diminishing pulse pressure occurs with:
mitral or aortic stenosis, which occurs with mechanical obstruction
constricted peripheral vessels, which occurs with shock
declined stroke volume, which occurs with heart failure, hypovolemia, cardiac tamponade, or tachycardia.
RADIAL PULSE ASSESSMENT
If you suspect cardiac disease, palpate the radial pulse for 1 full minute to detect arrhythmias. Normally, an adult’s pulse ranges from 60 to 100 beats/minute. Its rhythm should feel regular, except for a subtle slowing on expiration, caused by changes in intrathoracic pressure and vagal response. Note whether the pulse feels weak, normal, or bounding.
RESPIRATION EVALUATION
Observe for eupnea—a regular, unlabored, and bilaterally equal breathing pattern. In patients with irregular breathing, altered patterns may indicate:
tachypnea with low cardiac output
dyspnea, a possible indicator of heart failure (not evident at rest; however, pausing occurs after only a few words to take breaths)
Cheyne-Stokes respirations, possibly accompanying severe heart failure (seen especially with coma)
shallow breathing, possibly seen with acute pericarditis (deep respirations occur in an attempt to reduce the pain associated with deep respirations).
General appearance assessment
Begin by observing the patient’s general appearance, particularly noting weight and muscle composition. Is he well developed, well nourished, alert, and energetic? Document any departures from normal. Does the patient appear older than his chronological age or seem unusually tired or slow-moving? Does the patient appear comfortable or does he seem anxious or in distress?
HEIGHT AND BODY WEIGHT MEASUREMENT
Accurately measure and record the patient’s height and weight. These measurements will help:
determine risk factors
calculate hemodynamic indexes (such as cardiac index)
guide treatment plans
determine medication dosages
assist with nutritional counseling
detect fluid overload.
Fluctuations in weight may prove significant, especially when extreme.
RED FLAGExtreme weight fluctuation, for example, would occur if the patient with developing heart failure gains several pounds overnight.
Next, assess for cachexia—weakness and muscle wasting. Observe the amount of muscle bulk in the upper arms, thighs, and chest wall. For a more precise measurement, calculate the percentage of body fat. For men, this should be 12%; for women, it should be 18%. Loss of the body’s energy stores slows healing and impairs immune function. A patient with chronic cardiac disease may develop cachexia. However, be aware that edema may mask these effects.
SKIN ASSESSMENT
Note the patient’s skin color, temperature, turgor, and texture. Because normal skin color can vary widely among patients, ask him if his current skin tone is normal. Then inspect the skin color and note any cyanosis. Two types of cyanosis can occur in patients:
central cyanosis, suggesting reduced oxygen intake or transport from the lungs to the bloodstream, which may occur with heart failure
peripheral cyanosis, suggesting constriction of peripheral arterioles, a natural response to cold or anxiety or a result of hypovolemia, cardiogenic shock, or a vasoconstrictive disease.
Examine the underside of the tongue, buccal mucosa, and conjunctiva for signs of central cyanosis. Inspect the lips, tip of the nose,
earlobes, and nail beds for signs of peripheral cyanosis. The color range for normal mucous membranes is narrower than that for the skin; therefore, it provides a more accurate assessment. In a darkskinned patient, inspect the oral mucous membranes, such as the lips and gingivae, which normally appear pink and moist but would appear ashen if cyanotic.
earlobes, and nail beds for signs of peripheral cyanosis. The color range for normal mucous membranes is narrower than that for the skin; therefore, it provides a more accurate assessment. In a darkskinned patient, inspect the oral mucous membranes, such as the lips and gingivae, which normally appear pink and moist but would appear ashen if cyanotic.
When evaluating the patient’s skin color, also observe for flushing, pallor, and rubor. Flushing of a patient’s skin can result from:
medications
excess heat
anxiety
fear.
Pallor can result from anemia or increased peripheral vascular resistance caused by atherosclerosis. Dependent rubor may be a sign of chronic arterial insufficiency.
Next, assess the patient’s perfusion by evaluating the arterial flow adequacy. With the patient lying down:
Elevate one of the patient’s legs 12″ (30.5 cm) above heart level for 60 seconds.
Tell him to sit up and dangle both legs.
Compare the color of both legs.
The leg that was elevated should show mild pallor compared with the other leg. Color should return to the pale leg in about 10 seconds, and the veins should refill in about 15 seconds. Suspect arterial insufficiency if the patient’s foot shows marked pallor, delayed color return that ends with a mottled appearance, delayed venous filling, or marked redness.
Next, touch the patient’s skin. It should feel warm and dry. If the patient’s skin is cool and clammy, this is a sign of vasoconstriction, which occurs when cardiac output is low such as during shock. Warm, moist skin is a sign of vasodilation, which occurs when cardiac output is high such as during exercise.
Evaluate skin turgor by grasping and raising the skin between two fingers and then letting it go. Normally, the skin immediately returns to its original position. If the patient’s skin is taut and shiny and can’t be grasped, this may result from ascites or the marked edema that accompanies heart failure. Skin that doesn’t immediately return to the original position exhibits tenting, a sign of decreased skin turgor, which may result from:
dehydration, especially if the patient takes diuretics
age
malnutrition
adverse reaction to corticosteroid treatment.
Observe the skin for signs of edema. Inspect the patient’s arms and legs for symmetrical swelling. Because edema usually affects lower or dependent areas of the body first, be especially alert when assessing the arms, hands, legs, feet, and ankles of an ambulatory patient or the buttocks and sacrum of a bedridden patient. Determine the type of edema (pitting or nonpitting), its location, its extent, and its symmetry (unilateral or symmetrical). If the patient has pitting edema, assess the degree of pitting.
Edema can result from heart failure or venous insufficiency caused by varicosities or thrombophlebitis. Chronic right-sided heart failure may cause ascites, which leads to generalized edema and abdominal distention. Venous compression may result in localized edema along the path of the compressed vessel.
While inspecting the patient’s skin, note the location, size, number, and appearance of any lesions. Dry, open lesions on the patient’s lower extremities accompanied by pallor, cool skin, and lack of hair growth signify arterial insufficiency, possibly caused by arterial peripheral vascular disease. Wet, open lesions with red or purplish edges that appear on the patient’s legs may result from the venous stasis associated with venous peripheral vascular disease.
EXTREMITY ASSESSMENT
Inspect the hair on the patient’s arms and legs. Hair should be distributed symmetrically and should grow thicker on the anterior surface of the arms and legs. If the patient’s hair isn’t thicker on the anterior of the surface of the arms and legs, it may indicate diminished arterial blood flow to these extremities.
Note whether the length of the arms and legs is proportionate to the length of the trunk. A patient with long, thin arms and legs may have Marfan syndrome, a congenital disorder that causes cardiovascular problems, such as:
aortic dissection
aortic valve incompetence
cardiomyopathy.
FINGERNAIL ASSESSMENT
Fingernails normally appear pinkish with no markings. A bluish color in the nail beds indicates peripheral cyanosis.
Estimate the rate of peripheral blood flow; assess the capillary refill in the patient’s fingernails (or toenails) by applying pressure to the nail for 5 seconds, then assessing the time it takes for color to return.
In a patient with a good arterial supply, color should return in less than 3 seconds.
In a patient with a good arterial supply, color should return in less than 3 seconds.
CHECKING FOR CLUBBED FINGERS
To assess a patient for chronic tissue hypoxia, check his fingers for clubbing. Normally, the angle between the fingernail and the point where the nail enters the skin is about 160 degrees. Clubbing occurs when that angle increases to 180 degrees or more, as shown below.
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Delayed capillary refill in the patient’s fingernails suggests reduced circulation to that area, a sign of low cardiac output that may lead to arterial insufficiency.
Assess the angle between the nail and the cuticle. An angle of 180 degrees or greater indicates finger clubbing. Check for enlarged fingertips with spongy, slightly swollen nail bases. Normally, the nail bases feel firm; however, in early clubbing, they’re spongy. Finger clubbing commonly indicates chronic tissue hypoxia. (See Checking for clubbed fingers.)
The shape of the patient’s nails should be smooth and rounded. A concave depression in the middle of a thin nail indicates koilonychia (spoon nail), a sign of iron deficiency anemia or Raynaud’s disease, whereas thick, ridged nails can result from arterial insufficiency.
Finally, check for splinter hemorrhages—small, thin, red or brown lines that run from the base to the tip of the nail. Splinter hemorrhages develop in patients with bacterial endocarditis.
EYE ASSESSMENT
Inspect the eyelids for xanthelasma—small, slightly raised, yellowish plaques that usually appear around the inner canthus. The plaques
that occur in xanthelasma result from lipid deposits and may signal severe hyperlipidemia, a risk factor of cardiovascular disease.
that occur in xanthelasma result from lipid deposits and may signal severe hyperlipidemia, a risk factor of cardiovascular disease.
Next, observe the color of the patient’s sclerae. Yellowish sclerae may be the first sign of jaundice, which occasionally results from liver congestion caused by right-sided heart failure.
Next, check for arcus senilis—a thin grayish ring around the edge of the cornea. A normal occurrence in elderly patients, arcus senilis can indicate hyperlipidemia in patients younger than age 65.
Using an ophthalmoscope, examine the retinal structures, including the retinal vessels and background. The retina is normally light yellow to orange, and the background should be free from hemorrhages and exudates. Structural changes, such as narrowing or blocking of a vein where an arteriole crosses over, indicate hypertension. Soft exudates may suggest hypertension or subacute bacterial endocarditis.
HEAD MOVEMENT ASSESSMENT
Assess the patient’s head at rest and be alert for abnormal positioning or movements. Also check range of motion and rotation of the neck. A slight, rhythmic bobbing of the patient’s head in time with his heartbeat (Musset’s sign) may accompany the high backpressure caused by aortic insufficiency or aneurysm.
Heart assessment
Ask the patient to remove all clothing except his underwear and to put on an examination gown. Have the patient lie on his back, with the head of the examination table at a 30- to 45-degree angle. Stand on the patient’s right side if you’re right-handed or his left side if you’re left-handed so you can auscultate more easily.
When assessing the heart, as with assessing other body systems, use the following steps:
inspect
palpate
percuss
auscultate.
INSPECTION
First, inspect the patient’s chest and thorax. Expose the anterior chest and observe its general appearance. Normally, the lateral diameter is twice the anteroposterior diameter. Note any deviations from typical chest shape. (See Identifying chest deformities, page 36.)
Note landmarks you can use to describe your findings as well as structures underlying the chest wall. (See Identifying cardiovascular landmarks.)
Look for pulsations, symmetry of movement, retractions, or heaves. A heave is a strong outward thrust of the chest wall and occurs during systole.
Position a light source, such as a flashlight or gooseneck lamp, so that it casts a shadow on the patient’s chest. Note the location of the
apical impulse. This is typically also the point of maximum impulse (PMI) and should be located in the fifth intercostal space medial to the left midclavicular line. The apical impulse gives an indication of how well the left ventricle is working because it corresponds to the apex of the heart. The impulse can be seen in about one-half of all adults.
apical impulse. This is typically also the point of maximum impulse (PMI) and should be located in the fifth intercostal space medial to the left midclavicular line. The apical impulse gives an indication of how well the left ventricle is working because it corresponds to the apex of the heart. The impulse can be seen in about one-half of all adults.
AGE AWAREIn children and patients with thin chest walls, the apical impulse is noted more easily. In these patients, you may see slight sternal movement and pulsations over the pulmonary arteries or the aorta as well as visible pulsations in the epigastric area. To find the apical impulse in a woman with large breasts, move the breasts during the examination.
On inspection, irregularities in the patient’s heart may be noted. Some of these findings can impair cardiac output by preventing chest
expansion and inhibiting heart muscle movement, whereas others can indicate cardiac disease:
expansion and inhibiting heart muscle movement, whereas others can indicate cardiac disease:
barrel chest, indicated by a rounded thoracic cage caused by chronic obstructive pulmonary disease
pectus excavatum, indicated by a depressed sternum
scoliosis, which is a lateral curvature of the spine
pectus carinatum, indicated by a protruding sternum
kyphosis, which is a convex curvature of the thoracic spine
retractions, indicated by visible indentations of the soft tissue covering the chest wall, or the use of accessory muscles to breathe, which typically results from a respiratory disorder, but may also indicate a congenital heart defect or heart failure
visible pulsation to the right of the sternum, a possible indication of aortic aneurysm
pulsation in the sternoclavicular or epigastric area, a possible indication of aortic aneurysm
sustained, forceful apical impulse, a possible indication of left ventricular hypertrophy, which increases blood pressure and may cause cardiomyopathy and mitral insufficiency
laterally displaced apical impulse, a possible sign of left ventricular hypertrophy.
PALPATION
Maintain a gentle touch when palpating so you won’t obscure pulsations or similar findings. Follow a systematic palpation sequence covering the sternoclavicular, aortic, pulmonary, right ventricular, left ventricular (apical), and epigastric areas. Use the pads of the fingers to effectively assess large pulse sites. Finger pads prove especially sensitive to vibrations.
Start at the sternoclavicular area and move methodically through the palpation sequence down to the epigastric area. At the sternoclavicular area, you may feel pulsation of the aortic arch, especially in a thin or average-build patient. In a thin patient, you may palpate a pulsation in the abdominal aorta over the epigastric area.
Starting with the ball of your hand then using your fingertips, palpate over the precordium to find the apical impulse. Note heaves or thrills, fine vibrations that feel like the purring of a cat. (See Palpating the apical impulse.)
Keep in mind that the apical impulse may be difficult to palpate in obese patients, pregnant women, and patients with thick chest walls.
If it’s difficult to palpate with the patient lying on his back, have him lie on his left side or sit upright. It may also be helpful to have the patient exhale completely and hold his breath for a few seconds.
Palpation of the patient’s heart may reveal:
apical impulse that exerts unusual force and lasts longer than one-third of the cardiac cycle—a possible indication of increased cardiac output
displaced or diffuse impulse—a possible indication of left ventricular hypertrophy
pulsation in the aortic, pulmonary, or right ventricular area—a sign of chamber enlargement or valvular disease
pulsation in the sternoclavicular or epigastric area—a sign of aortic aneurysm
palpable thrill or fine vibration—an indication of blood flow turbulence, usually related to valvular dysfunction (Determine how far the thrill radiates and make a mental note to listen for a murmur at this site during auscultation.)
heave or a strong outward thrust during systole along the left sternal border—an indication of right ventricular hypertrophy
heave over the left ventricular area—a sign of a ventricular aneurysm (A thin patient may experience a heave with exercise, fever, or anxiety because of increased cardiac output and more forceful contraction.)
displaced PMI—a possible indication of left ventricular hypertrophy caused by volume overload from mitral or aortic stenosis, septal defect, acute MI, or other disorder.
PERCUSSION
Although percussion isn’t as useful as other methods of assessment, this technique may help in locating cardiac borders. Begin percussing at the anterior axillary line, and percuss toward the sternum along the fifth intercostal space.
The sound changes from resonance to dullness over the left border of the heart, normally at the midclavicular line. If the cardiac border extends to the left of the midclavicular line, the patient’s heart—and especially the left ventricle—may be enlarged.
The right border of the heart is usually aligned with the sternum and can’t be percussed. In obese patients and women, percussion may be difficult because of the fat overlying the chest and because of breast tissue. In these cases, a chest X-ray can be used to provide information about the heart border.
AUSCULTATION
Auscultating for heart sounds provides a great deal of information about the heart. Cardiac auscultation requires a methodical approach and plenty of practice. Begin by warming the stethoscope in your hands, and then identify the sites where you’ll auscultate: over the four cardiac valves and at Erb’s point, the third intercostal space at the left sternal border. Use the bell to hear low-pitched sounds and the diaphragm to hear high-pitched sounds. (See Using auscultation sites.)
Auscultate for heart sounds with the patient in three positions:
lying on his back with the head of the bed raised 30 to 45 degrees
sitting up
lying on his left side.
Use a zigzag pattern over the precordium, either auscultating from the base to the apex or the apex to the base. Whichever approach you use, be consistent.
Use the diaphragm of the stethoscope to listen as you go in one direction; use the bell as you come back in the other direction. Be sure to listen over the entire precordium, not just over the valves. Note the heart rate and rhythm.
Always identify the first heart sound (S1) and the second heart sound (S2), and then listen for adventitious sounds, such as third (S3) and fourth heart sounds (S4), murmurs, and rubs.
USING AUSCULTATION SITES
When auscultating for heart sounds, place the stethoscope over four different sites. Follow the same auscultation sequence during every cardiovascular assessment:
Place the stethoscope in the second intercostal space along the right sternal border, as shown. In the aortic area, blood moves from the left ventricle during systole, crossing the aortic valve and flowing through the aortic arch.
Move to the pulmonic area, located in the second intercostal space at the left sternal border. In the pulmonic area, blood ejected from the right ventricle during systole crosses the pulmonic valve and flows through the main pulmonary artery.
In the third auscultation site, assess the tricuspid area, which lies in the fifth intercostal space along the left sternal border. In the tricuspid area, sounds reflect blood movement from the right atrium across the tricuspid valve, filling the right ventricle during diastole.
Finally, listen in the mitral area, located in the fifth intercostal space near the midclavicular line. (If the patient’s heart is enlarged, the mitral area may be closer to the anterior axillary line.) In the mitral (apical) area, sounds represent blood flow across the mitral valve and left ventricular filling during diastole.
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Normal heart sounds
Start auscultating at the aortic area where S2 is loudest. S2 is best heard at the base of the heart at the end of ventricular systole. This sound corresponds to closure of the pulmonic and aortic valves and is generally described as sounding like “dub.” It’s a shorter, higherpitched, louder sound than S1. When the pulmonic valve closes later than the aortic valve during inspiration, you’ll hear a split S2.
From the base of the heart, move to the pulmonic area and down to the tricuspid area. Then move to the mitral area, where S1 is the loudest. S1 is best heard at the apex of the heart. This sound corresponds to closure of the mitral and tricuspid valves and is generally
described as sounding like “lub.” It’s low-pitched and dull. S1 occurs at the beginning of ventricular systole. It may be split if the mitral valve closes just before the tricuspid.
described as sounding like “lub.” It’s low-pitched and dull. S1 occurs at the beginning of ventricular systole. It may be split if the mitral valve closes just before the tricuspid.
QUICK GUIDE TO EXTRA HEART SOUNDS
This chart lists some common extra heart sounds along with their characteristics.
SOUND | LOCATION | PITCH | TIMING | PATIENT POSITION | CAUSE |
|---|---|---|---|---|---|
S3 | Apex | Low | Early to middiastole | Supine or left lateral | Noncompliant ventricle |
S4 | Mitral or tricuspid area (with bell of stethoscope) | Low | Late diastole | Supine | Atrial contraction into a noncompliant ventricle |
Summation gallop | Apex | Low | Middiastole | Left lateral | S3 and S4 occurring together to produce one heart sound |
Quadruple rhythm | Apex | Low | Throughout cardiac cycle | Left lateral | Hearing S1, S2, S3, and S4 |
Click | Apex or lower left sternal border | High | Mid to late systole | Sitting or standing | Tensing of the chordae tendineae and mitral valve cusps |
Snap | Apex along lower left sternal border | High | Mid to late diastole | Left lateral | Stenotic valve attempting to open |
Rub | Third left intercostal space at the lower left sternal border | High | Throughout systole, diastole, or both | Leaning forward | Pericarditis |
Auscultation may detect S1 and S2 that are accentuated, diminished, or inaudible. These abnormalities may result from:
pressure changes
valvular dysfunctions
conduction defects.
A prolonged, persistent, or reversed split sound may result from a mechanical or electrical problem.
Abnormal heart sounds
Auscultation may reveal an S3, an S4, or both. Other abnormal sounds include a summation gallop, click, opening snap, rubs, and murmur. (See Quick guide to extra heart sounds.)
S3
Also known as a ventricular gallop, S3 is a low-pitched noise that’s best heard by placing the bell of the stethoscope at the apex of the heart. Its rhythm resembles a horse galloping, and its tempo resembles the word “Ken-tuc-ky” (lub-dub-by). Listen for S3 with the patient in a supine or left-lateral decubitus position.
S3 usually occurs during early diastole to middiastole, at the end of the passive-filling phase of either ventricle. Listen for this sound immediately after S2. It may signify that the ventricle isn’t compliant enough to accept the filling volume without additional force. If the right ventricle is noncompliant, the sound will occur in the tricuspid area; if the left ventricle is noncompliant, in the mitral area. A heave may be palpable when the sound occurs.
AGE AWAREIn a child or young adult, S3 may occur normally. It may also occur during the last trimester of pregnancy. In a patient over age 30, it usually indicates a disorder, such as right-sided heart failure, left-sided heart failure, pulmonary congestion, intracardiac shunting of blood, MI, anemia, or thyrotoxicosis.
S4
S4 is an abnormal heart sound that occurs late in diastole, just before the pulse upstroke. It immediately precedes the S1 of the next cycle and is associated with acceleration and deceleration of blood entering a chamber that resists additional filling. Known as the atrial or presystolic gallop, it occurs during atrial contraction.
S4 shares the same tempo as the word “Ten-nes-see” (le-lub-dub). Heard best with the bell of the stethoscope and with the patient in a supine position, S4 may occur in the tricuspid or mitral area, depending on which ventricle is dysfunctional.
AGE AWAREIn elderly patients, S4 commonly appears with age-related systolic hypertension and aortic stenosis.
Although rare, S4 may occur normally in a young patient with a thin chest wall. More commonly, it indicates cardiovascular disease, such as:
acute MI
hypertension
CAD
cardiomyopathy
angina
anemia
elevated left ventricular pressure
aortic stenosis.
If the sound persists, it may indicate impaired ventricular compliance or volume overload.
Summation gallop
Occasionally, a patient may have both S3 and S4
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