Cardiac patient assessment: puttingthe patient first

Curie Scott, )ulie D Macinnes

AbstractNursing roles are expanding and there is a growing expectationthat nurses, with appropriate education and experience, areable to perform assessments that were traditionally conductedby doctors. This article discusses patient history., vital signs andphysical exainination related to the cardiac patient. This will enablepractitioners to enhance their knowledge and understanding of thisvaluable assessment influencing patient care.

Key words: Heart disorders: prevention and screeningassessment

Patient

Nursing roles are expanding and there is a growingexpectation that nurses, with appropriateeducation and experience, are able to performassessments that were traditionally conducted

by doctors (NHS Management Executive, 1991; UnitedKingdom Central Council of Nursing, Midwifery andHealth Visitnig (UKCC) (1992).

A comprehensive, systematic patient assessment is necessaryin the management and care of a patient with cardiac disease.Assessment can be described as 'an orderly collection otinformation concerning the patient's health status whichaitns to identity the patient's current health status, actual andpotential health problems and areas for health improvement'(Estes,2002 p7).

Assessment requires a prohlem-solving approach andforms the first stage of the nursmg process, followed bynursing diagnosis, identification of problems, interventionand evaluation.

Assessment consists of:• Patient history• Determination of vital signs or nursing observations• Physical examination• Diagnostic investigations.

Traditionally, the nursing role in patient assessment wouldbe restricted to elements of patient history and nursingobservations. However, nurses performing advanced rolesincreasingly perform physical examination in addition torequesting and interpreting many diagnostic investigations.

C'urie Scott is Senior LectiiriT and Julie I) M.iclniics is Senior Lecturer

in Cardiac ('are, Department of AcUilt Nursing Studies, tl^ncorburyC]hrist C^hiirch University, Qioterbury, Kent

Accepted for publication: March 2006

A comprehensive assessment may be based on a nursingmodel, for example that by Roper et al (1980) whichencompasses the activities of daily living. This modelincorporates the risk of pressure sore development and aniitritioTial, cultural and spiritual assessment. In contrast,patient assessment may be necessarily brief and .succinctin an acutely or critically ill patient, allowing for a morecomprehensive assessment at a later stage. In this situation theadoption of a focused assessment using an 'AliC approach,where airway, breathing and circulation are priorities, isoften utilized. An 'early warning sign' system uses thisAUC approach to quickly identify those patients at riskof deterioration and who require immediate intervention(McArthur-Rouse, 20(11).

This article utilizes a systematic approach to appraiseselected aspects relevant tor a cardiac patient assessment.These include history taking, which encompasses symptomassessment, past medical history, assessment of risk factors,medication, family history and social history. Vital signs (orntirsing observations) are exploreci in addition to physicalexamination. The latter section considers a variety ofsignificant details that can be observed in the cardiac patientwhen assessing hohsticaily Underpinning anatomy andphysiology will be integrated throughout the discussion.

Cardiac patient historyI'atient history is frequently the first element in a systematicpatient assessment. It includes an exploration of symptomsand the determination of past medical history, medications,family and social history together with an assessment of riskfactors for cardiac disease. Much of the information abouta potential diagnosis is ascertained by the history so thatfurther findings from the actual examination and tests are toconfirm the probable cause.

Symptom assessmentPatients' symptoms need to be scrutinized by the practitionerto determine if these relate to an underlying cardiac conditionin order to influence appropriate management.

Though chest pain is the most obvious and commoncardiac symptom, breathlessness, oedema, palpitations,syncope and fatigue are also described (Gieadle, 2003;Jowettand Thompson, 2003). Table 1 gives examples of questionsthat practitioners may use.

Chest painThe National Service Framework for Coronary Heart Disease(Department of Health (DH), 2000) advocates the rapid

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assessment of chest pain to exclude non-cardiac chest painand to enable the prompt treatment of stable angina antlacute coronary syndrome (ACS). Rapid access chest painclinics are now commonplace {Wood andTininiis, 2001) andwere developed to facilitate the differential diagnosis of chestpain and instigate appropriate treatment. Stable angina maybe defined as symptomatic myocardial ischaeniia with chestpain lasting less than 5 minutes. It is commonly precipitatedby exercise or stress, occurring over a number of weekswithout significant deterioration Qowett and Thompson,2(>()3). In contrast, ACS can be divided into two groupsdifferentiated by electrocardiogram (ECG) changes andcardiac markers assessed from a venous blood sample. Thefirst group is ST elevation myocardial infarction (STEMI).and the second consists of unstable angina (UA) and non-ST elevation MI (NSTEMI). STEMI presents as symptomsof niyocardial ischaeniia coupled with ST elevation ornew bundle branch block (BBB) on the ECG. UA andNSTEMI are also characterized by symptoms of myocardialischaeniia but without ST elevation. UA and NSTEMI caiibe differentiated by cardiac markers.

When heart muscle (myocardium) is deprived of ox '̂genas a result of insufficient blood supply, ischaemic pain isthe consequence. This ischaeniia occurs when there isthickening and hardening of the vessel walls (arteriosclerosis)and deposition of'plaques' containing cholesterol, lipids andfibrin in the inner walls (atherosclerosis) (Hrashers, 2004).Although arteriosclerosis is a normal conseqtience of aging,hypertension, high cholesterol (hypercholesterolaemia),smoking and diabetes can aggravate both processes.

Classically., ischaemic chest pain presents as central chest pain.radiating to one or both arms,jaw or back. It is often describedas a pressure, heaviness or ache, although it may be atypical.It may be of gradual or sudden onset and can be precipitatedby exertion, cold or anxiety. It may be reheved by rest ormedication, for example, glyceryl trinitrate (GTN). In ACS,associated symptoms include tiausea, vomiting and sweating.

In contrast, when the outer wall of the heart (pericardium)IS mflamed, a condition known as pericarditis, the paindiffers. Here, it is often described as a sharp, central chestpain unrelated to exertion, aggravated by inspiration orcoughing and relieved hy sitting forward. The mnemonic'PQRST' (outlined in Taiyle 2) is frequently cited as astructured method m the differential diagnosis of chest pain(Estes. 2(HI2; Spriiighouse, 2()(t2) and its use is transferableto other symptoms.

Other origins of non-cardiac chest pain include aorticdissection, pulmonary embolism, pneumothorax, pneumoniaand chest infections, oesophageal disorders (includingindigestion and reflux), musculoskeletal, anxiety and post-operative pain (Fallon and Roques. 1997). Hence, a thorough,foctised assessment of chest pain is vital as an adjunct topatient history aiid physical examination.

DyspnoeaDyspnoea, or shortness of breath, may occur as a result of,1 respiratory condition but is a major symptom in patientswith cardiac problems, especially in heart failure. Hearttailure is defined by Jowett and Thompson (2003, p254) as a

'clinical syndrome that results from an inahility of the heartto provide an adequate cardiac output'.

Patients with dyspnoea have a heightened awareness otuncomfortable, distressing or laboured breathing either at restor after a low level of exertion (Beers and Berkow. 2005).The reasoning for dyspnoea is complex but is su^ested to bemainly as a result of dysfunction of the left ventricle. Normally,oxygenated blood moves from the lungs into the left side ofthe heart, flowing from the atrium into the ventricle {Hi^ure /);therefore, increased pressure in the left ventricle will eventuallyresult in back-pressure in the lung capillaries. This highpressure causes fluid to be forced out of the blood into thetissue spaces (interstitial space) causing pulmonary congestion.Other factors include stiffening of the lung, respiratory musclefatigue and acidosis (Timmis and Mills, 2002).

It is important to note the type and extent of exertion thatcauses dyspnoea (e.g. shopping, climbing stairs or walking)and whether exercise tolerance has deteriorated. In advancedheart fliilure patients may have dyspnoea at rest.

Pulmonary congestion related to heart disease gives rise toorthopnoea and paroxysmal nocturnal dyspnoea. Orthopnoeais when breathlessness causes patients to be unable to lie flatand therefore use extra pillows or sit in a chair to sleep. Thepatient with paroxysmal nocturnal dyspnoea will describewaking suddenly from sleep (often trom lying flat) with acutedyspnoea and a sense of impending doom that is rectified onstanding (Timmis and Mills, 2002).

Pulmonarysemilunar valve

Left pulmonary veins

Left atnum

Mitral (bicuspid) valve

Right atrium

Tricuspid valve

Inferior vena cava

>• Oxygenated blood

• Deoxygenated blood

Venules4 Systemic^ capiUarie

Pencardial fluidPericardium

Figure 1. Anatomy of the heart and normal route of blood jlow.

l nf Nursing, 2U()6.Vol IS. No 503

PalpitationsPatients may convey an awareness of their heartbeat hyusing terms such as their heart races, flutters, pounds, skipsor misses a beat. To demonstrate the regularity and rate, thepatient can be asked to tap out the rhythm. Initiating factorsshould be queried and whether the palpitations started andstopped suddenly or gradually (Bickley and Szihiygi, 2003).Palpitations could occur as a result of an arrhythmia causingthe heart to beat at an abnormal rate or irregularly or becausethe heart is beating more forcefully (Epstein et al, 2003).

OedemaIn addition to pulmonary congestion, pressure may increasein the right atrium causing backpressure in the systemicvenous system {Fiiiure 1). Fluid may then accumulate inthe interstitial space and produce swelling of the feet withpatients revealing that their shoes, rings or clothes havebecome tight. Gravity plays a role here as patients may notethat their swollen feet are worse in the evening and betterin the morning.

Table I. examples of question to analyse specificsymptoms

Chest pain:• Have you had any pain or pressure in your chest, neck or arm?

If 'yes' _ the following questions are necessary:o Can you describe the pain?o Where exactly is the pain?o How often does it occur and how long does it last?o How severe is the pain?o What brings the pain on?o What makes the pain better or worse?o Does the pain radiate anywhere?

o Have you had any other symptoms (e.g. nausea, vomiting, sweating)?Dyspnoea:• Are you short of breath on exertion?

o If yes' _ how much exertion is necessary to make you short of breath?• Are you short of breath when you are not doing anything (i.e. at rest)?• Can you lie flat without feeling breathless?

o If 'no' _ how many pillows do you need to sleep? Do you sleep in a chair?• Have you ever woken suddenly from sieep short of breath?Palpitations:• Are you ever aware of your heart beating, for exampie, racing or beating

irregularly?o If 'y^s' _ Couid you describe what this is like?o If "y^s' _ When does the sensation occur?

Oedema:• Have you noticed swelling of your ankles?• Have you noticed that your shoes, rings or clothes feel restrictive, especiaily at

the end of the day?Syncope:• Have you ever felt light headed/ dizzy or fainted?• If 'y^s" _ could you describe what happened?• If 'y^s' _ did you have any warning signs• If yes" _ did anyone witness this (get a statement of what was seen If possible)Poor peripheral circulation:• Do you have cold or blue hands or feet?• Do you have pain in your legs on exercise?

o If yes' _ how much exertion is necessary to produce this pain?o If 'y^s' _ what helps the pain disappear?

SyncopeThe processes of arteriosclerosis and atherosclerosis describedabove may result in decreased blood flow to the brain. Thismay cause a temporary loss of consciousness, defined assyncope, but verbalized by patients as fainting or a blackout.If this has occurred, an additional description of the episodefrom an observer is useful (Hattoii and Blackwood, 2003).

Poor peripheral circulationCardiac patients may have poor blood flow to theirperipheries and therefore have colder feet or hands whichmay appear paler in comparison to the surrounding areas.Additionally, they may experience intermittent claudication- this is pain experienced in one or both legs when walkingand IS reheved by rest (Epstien et al, 2003). The situationis similar to that discussed above in relation to myocardialischaemia, although instead of coronary artery narrowingit occurs in the arteries in the leg and heralds existence ofperipheral vascular disease. The pain is aching in nature andpresents in the calt, thigh or buttocks.

Past medical history (PMH) and assessment ofcardiac risk factorsAn analysis of a patient s previous and current illnesses canbe obtained from an interview with the patient and taniilymembers and from medical notes. Establishing any previousacute or chronic cardiac disease is of value. This includesthe presence of existing coronary heart disease (CHD)as evidenced by previous niyocardial infarction or anginain addition to any previous cardiac surgery or congenitalcardiac abnormalities.

The existence of other diseases or risk factors associatedwith CHD, such as hypertension, hypercholesterohiemia,cerebrovascular accidents (CVA) and diabetes niellitus (DM)should also be explored. The presence of childhood illnesssuch as rheumatic fever should be sought as the heart valvesmay be damaged so patients are at higher risk for endocarditis.Endocarditis relates to infection of the heart valves and, ifsuspected, then investigation into possible portals of entryof microorganisms (such as recent dental work) should bediscussed (Gieadle, 2003).

Additionally, in patients with suspected STEMI,contraindications for thrombolysis need confirmationthrough history and physical examination. For example,recent surgery or trauma, stroke, bleeding disorders oraortic dissection are absolute or relative contraindications tothrombolysis (Jowett and Thompson, 2003),

MedicationCurrent medications, including prescription, over the counterand herbal medications, should be ascertained as they mayaffect cardiac function or interact with any new drugs that areprescribed. The use of recreational drugs must be addresseddue to their potential effect on cardiac rhythm. Often, scrutinyof a patient's medications draws attention to a condition thathas not been disclosed previously, for example, a patient maynot mention hypertension as their blood pressure is nowcontrolled by medication. It is usual, while enquiring aboutmedication, to note if the patient has any allergies.

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CARDIAC ASSESSMENT

Family and social historyFamily history is the report of the occurrences of familialor genetic diseases. In the cardiac patient, this mightinclude CHD, DM, CVA, familial hypercholesterolaemia,hypertension, cardiomyopathy, congeiHtal heart disease orsudden death (Gieadle, 2003).

Social history explores information about the patient'slifestyle that affects health. In the cardiac patient this mightinclude an analysis of established modifiable risk behaviourfor CHD including smokmg, a diet high in saturated fats,lack of exercise, excessive alcohol consumption and stress.The use of a risk calculator may be used to establish apatient's risk status using specific information such as gender,age, serum cholesterol levels and other risk factors (Foxton,20(14). This not only indicates level of risk but also providesa mechanism for targeting and evaluating heaith promotmgstrategies. Work and home environment, leisure activitiesand social role would also need to be assessed to determinecontinuing care needs.

Vital signsVital signs are of paramount importance in ascertainingthe patients clinical condition and underpin physicalexamination. Those that directly relate to the cardiovasctilarsystem include the pulse and blood pressure. However, othersigns that may be useful are the patient's respiratory rate,temperature and level of consciousness.

PulseMost commonly, the radial artery is used to assess the rateand rhythm of the pulse. Bradycardia (<6(J beats per minute)may be caused by beta-blockade, hypoxia or parasympathetic(vagal) stimulation. Tachycardia (>10() beats per minute)may be caused by pyrexia, hypovolaeniia, shock, anxiety orpain (Doherty, 2002). An irregular rhythm should promptfurther investigation through a 12-lead ECG. Conductiondisturbances, e.g. heart blocks and atrial fibrillation, arecommonly associated with cardiac disease. In cases of atria!fibrillation the rate should be measured by listening witha stethoscope at the apex (Timmis and MiDs, 2002). Thecharacter of the pulse should also be assessed, although thisis best assessed using the carotid artery. For example, a pulsemay be described as thready in cardiogenic shock; boundingin aortic insufficiency; or have decreased force if there isatherosclerotic narrowing or occlusion.

Blood pressureA systolic blood pressure of less than 9()mmHg is indicativeof poor circulation (Resuscitation Council UK, 2000).However, the mean arterial pressure (MAP) gives a betterindication of perfusion and a reading of 60 niniHg is neededto perfuse coronary arteries, the brain and kidneys. Thoughthis value is frequently established by blood pressure machines,it can be approximated from the usual blood pressure readingby: diastohc BP + (systolic BP - diastolic BP)/3.

The respiratory rate should be recorded as it is frec^uently anearly sign of deterioration in a patient's condition (Ryan et al,2004). An increased temperature may indicate endocarditis orpericarditis and is also apparent after a myocardial infarction

Table 2. Exploration of symptoms

p

QRS

T

FactorsProvoking or PalliativeQuality or QuantityRegion and RadiationSeverity

Timing

The patient Is asked...What makes the symptom worse or betterWhat the symptom feels/looks/ sounds likeWhere the symptom occurs and if it radiates anywhereHow severe tfie symptom is (rating scaies can be used)Whetfier the symptom intensity has alteredThe effect on normal activitiesWhen the symptom began and if it was sudden orgradualThe frequency of the symptomHow long the symptom lasts

(Tininiis and Mills, 2002) or post-surgical infection. In thecardiac patient, hypoxia and CVA may both be evidencedby alteration in neurological status, therefore, neurologicalobservations and scoring systems such as the Glasgow ComaScale should be recorded.

Physicai examinationA comprehensive assessment includes the examination ofall body systems. The term physical examination includesthe interpretation of observable signs. A noteworthy pointis that the abihty to perform a cardiovascular assessment andpercussion/auscultation of the chest are skills practitionershave identified as being valuable (Rushworth et al, 1998).

Overview of cardiac physical assessmentThe cardiovascular examination requires exposure of thepatient's chest which may cause patients to be apprehensiveabout potential findings and possible pain. Therefore, it isimperative to be sensitive and to ensure surroundings areappropriate for the examination to maintain privacy anddignity (Epstein et al, 2003).

Although the formal method of cardiac examination willbe explored, several aspects will have been noted whenthe patient is first seen, during the history taking and fromrecording of vital signs. The four principles of assessmentthat can he applied in most system-based assessments areinspection, palpation, percussion and auscultation {Table 3)though percussion is not integral to cardiac assessment.

As the effects of cardiac disease often have an impact onthe whole body, it is vital to survey the whole patient ratherthan focus immediately on the chest. The initial inspectionmay include noting signs of distress (e.g. grimacing in pain).

Table 3. Principles of assessment

DescrintlonInspection

Palpation

Observation of the person as a whole in addition to a particular area(e.g. hands, face and chest)Technique using touch to determine the texture, temperature,moisture and organ sizeDescribes the transmission of sound elicited by the practitionertapping a finger with short sharp strokes against another finger that isfirmly positioned over a particular organ

Auscultation Uses both the bell and the diaphragm of a stethoscope to listen tosounds that internal organs produce

Percussion

i Juurriji of Nursing, 20116, Voi 15, No 505

breathlessness, an obvious skin colour cbange (paleness orcyanosis) and general physique {Bickley and Szilaytji, 2()()3).Sonic patients with easily observable conditions such asDowns Syndrome or Marfan Syndrome are at higher riskof cardiovascular problems. Chest wall deformities maycompress and displace the heart and there may be obviouspulsations from ancurysms (Tiiimiis and Mills, 2002).

Practitioners bave differing frameworks relating to theorder in which they assess patients but it is important to bemethodical and streamline the assessment to limit the numberof physical positions changed for the patient (Bickley andSzilaygi, 2003). However, most practitioners will commencethe cardiac examination at the patient's hands.

HandsOn inspection of the hands, signs of reduced peripheralperfusion such as peripheral cyanosis (blue discolouration)and reduced capillary refill time may be evident. Capillaryrefill is assessed by compressing the distal phalanx of themiddle finger for 5 seconds; once the pressure is releasedit should take approximately 2 seconds for the colour tobe regained, although this could be up to 4 seconds in tbeelderly (Epstein et al. 2003).

Although reduced cardiac output may cause decreasedperipheral pcrtusion, it is important to ensure the patient isnot cold as the same sign is observed. Additionally, nicotinestains and nail clubbing may be obvious. Clubbing isdistinguished by the oblkenition of the angle between thenail base and the adjacent skin, thickening ot tissue at thenail bed and the nail may be curved (Timmis and Mills,2002). Tlic underlying cause of clubbing is unknown but issuggested to be related to increased vascularity and increasedtissue fluid (Epstein et al, 2003) with cardiac causes beingcyanotic heart disease and endocarditis. An additional sign torthe latter are splinter baeniorrhages noted as tiny splinter-likelesions in the nail bed.The radial pulse sbould be palpated torthe rate and rhythm as discussed above.

Top of the internaljugular vein

(

^ ^ Vertical height of JVP (<4cm)

/» ' .Sternal angle

^y '/ ^ Sternum

y C ^ 2 ^ ^ ^ ^ ^ ^ ^ _ _ _ ^ Clavicle

r̂̂ —- • ^ ^ - - ^

Figure 2: How lo measure jugular yeiioiis pressure QV'l'}

1. Position ihe patient at 4S°. 2. Ask them to flex their head alightly and look straight ahead. The aimis to relax the stertiomastoid muscle. 3. Observe the internal jugular vein's transmitted pulsations justabove the elavicle. 4. Note the top of the pulsation. 5. Estimate the vertical height from the sternalangle to the top of the pulsation (it should be less than 4ctn).

Venous pulsations need to be distinguished from arterial pulsations. The JVP has an undulatingwai'eform with two pulsations per cardiac cycle, becomes pronounced if the abdomen is compressed overthe area of the liver (liepalojugular reflex) and is rarely palpable (Epstein et al, 2003).

The faceCeneral inspectionThe tace can then be assessed by noting tbe person's generalcolour and that ot the conjunctiva which may indicateanaemia. Patients may have signs of hypercholestcrolaenu'athat result in a greyish ring at the periphery of the cornea(an arcus) and yellow lesions under the skin (xanthelasma)often around the eyes. However, these are suggested to benon-specific in those over the age of 50 years (White, 2002).Finally, evidence of blue discolouration of the mouthsmucous membranes or tongue (central cyanosis) signifiesreduced oxygenation of the blood and should be noted.

Jugular venous pressureThe estimation of the jugular venous pressure (|VP), thoughdifficult to perform initially, is an assessment skill that isregularly used to estimate the patients blood volume stateand cardiac function (Bickley and Szilaygi. 2003). Theinternal jugular vein is observed for a reflection of centralvenous pressure which relates to right atrial pressure. Thetechnique is outlined in Fij^urc 2 and a normal JVP is 4 cmor lower. If, however, the JVP is too high to ascertain at a45° angle, the patient may have to be assessed in a sittingposition and this positional change must be documented.High JVP measurements can occur in congestive heartfailure, tamponade (excessive fluid within the double sacof the pericardium), fluid overload, pulmonary embolismand superior vena cava obstruction (Tiiiiniis and Mills2002).Tbose accustomed to evaluating the JVP gain furtherdetailed information by scrutinizing the JVP's undulatingcharacter known as 'the waveform".

Carotid pulseThe pulse character is assessed by carotid artery palpation andretlects iett ventricular function. Bilateral carotid pulses mustnot be compressed simultaneously and care should be takenthat the carotid sinus is not stimulated. These actions mayresult ill a reflex drop in pulse rate and blood pressure anddecreased blood flow to the brain causing syncope. Whilepalpating the carotid arteries, vibrations called 'tlirills' may beperceived and, when auscultated, these vascular, murnuir-likcsounds are termed 'bruits'.

The precordiumTbe assessment continues with observation of the chest wall.Any chest shape abnormalities and unusual pulsations shouldbe noted. Palpation to the left of the sternum will establishwhether the hand is lifted by eacb heartbeat (heaves) or ifheart murmurs are palpable (thrills). The mam purpose ofpalpation is to locate the apical impulse, or apex beat. Tliisis the most lateral site of impulse on the chest wall and,as this correlates to the contraction of the left ventricle,the assessment gives an indication o{ the condition of thischamber. In adults the apex beat is usually found in the mid-clavicular line at the 5th intercostal space on the left side. Itmay be necessary to roll the patient onto his left side (theleft lateral position) to detect it. Occasionally, the impulseis undetectable especially in patients who are obese, have amuscular chest wall or those with a barrel cbest (Bickley and

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CARDIAC ASSESSMENT

Szilaygi, 2003). The apical beat may be displaced if the heartbecomes enlarged and the quality of the beat may indicateincreased cardiac output, mitral stenosis or hypertrophy(Epstein et al,2003).

AuscultationThe purpose of auscultation is to establish whether heartsounds are normal and if there are any additional sounds.Thestethoscope must be placed directly on the skin and, ideally,the environment should be quiet. When a stethoscope isused listen to the heart, the resonance of a single heartbeatcorresponds to two heart sounds, otberwise known as 'lubdub', which originate from the closure of heart valves.

The atria till with blood and tben contract, pushing theblood into the ventricles. This is the beginning of systoleand, to prevent backtlow as the ventricles contract, thevalves between the atria and ventricles close securely. Thus,the first heart sound (lub or SI) occurs as a result of theclosure of the tricuspid and bicuspid valves. As systolecontinues, blood leaves the ventricles through open aorticand pulmonary valves and when these valves shut thesecond heart sound (dub or S2) is produced. This denotesthe end of systole and there is a short gap before the next setof heart sounds. This short period between S2 and the nextSI is diastole which signifies the time when the ventriclesare filling with blood. As valve closure on the right sideoccurs slightly later than the Iett side as a result of pressurechanges during inspiration, the nurse may distinguish twocomponents for each sound which may be a normal findingtermed pbysiological splitting.

The nurse may also distinguish a whooshing noise, knownas a heart murmur, which denotes abnormal turbulent tlowwhich may occur if a valve is damaged. When a valve doesnot close properly, the valve is 'incompetent'. The soundproduced is due to blood being refluxed or regurgitatedbackwards when the chamber contracts. Conversely, if thevalve does not open adequately, it is known as sclerosis orstenosis. If the murmur is heard between the two heart sounds(that is, during systole), they are termed systolic murmurs. If,however, they are heard during diastole they are designatedas diastolic murmurs.

The skill of distinguishing these abnormalities fromthe normal heart sounds occurs through practice andexposure to patients with conditions. However, correctuse of a stethoscope with two heads (a diaphragm anda bell) amplifies appropriate sounds. The chest shouldbe auscultated with the diaphragm of the stethoscopethroughout the precordium to detect the high pitchedsounds ot SI, S2, pericardial friction rubs and murmursfrom aortic and mitral regurgitation (Bickley and Szilaygi,2003). The bell is used to detect low pitched sounds of amitral stenosis murmur and further heart sounds termedS3 and S4. The sites tor auscultation are outlined in Figure3 and murmurs deriving from certain valves are louder inparticular areas which are named accordingly. It is worthnoting that these areas are not directly above the valvesconcerned. Tbere are various additional techniques used toaccentuate murmurs (Timmis and Mills, 2002; Bickley andSzilaygi, 2003; Epstein et al, 2003).

Figure 3: Cardiac auscultation. The diaphragm of the stethoscope is used

throughout the precordium to detect the high pitched sounds and the bell is

used to detect low pitched sounds at the apex then mot'ed medially along the

lower sternal border. ICS = intercostal space.

(

2nd ICS

Aortic area

/

ICS-lntercostal space

\

i

2nd ICSPulmonic area

/

• ^ — — '— • — —

ApexUsually in the 5th ICSMitral area

Left sternal border- -3 rd , 4th and 5th ICS

Tricuspid area

midclavicular line

Further examinationsIdeally, all major arteries should be assessed to check whetherpulses are present and for bruits and aneurysms. There maybe evidence of varicose veins, ulcers or oedema and acutearterial obstruction will classically present as a cold, pulseless,painful limb. Patients with heart failure may have evidence ofcrackles on lung auscultation and an enlarged spleen or liver.Extra information may be gleaned by assessing tbe retina forchanges related to hypertension and DM.

Finally, all intormation must be accurately recorded. Notonly is this a professional requirement (NMC, 2004) but itprovides a record of patient problems, the action taken, abaseline against which improvements or deterioration can bemade, and facilitates continuity of care.

ConclusionsThis article has enabled nurses to understand the most commoncardiac symptoms experienced and be equipped to enquireinto them. In addition, it has addressed vital signs and physicalexamination. Discussion of some aspects in this article havebeen introductory, for example, heart sound.s. Furthermore, acomprehensive assessment would also include diagnosticinvestigations, a fiinctional assessment and an assessment of allbody systems. It is envisaged that nurses undertaking advancedroles would seek to further develop their clinical skills throughcontinuing education and experience. uH

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Springhonse (2(M)2) Asses.inient made incredibly easy! 2nd edn. Springhousc,Pliiladclphia

Timmis A, Milk P (2002) The cardiovascular system. In: Swash M ad. Hutchison'sClinical Methods. 3rd edn.WB Saunders, London: 79-124

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KEY POINTS

I Patient assessment consists of patient history, vital signs,physical examination and diagnostic investigations.

I The patient may present with one of several cardiacsymptoms and the anaiysis of chest pain is mostsignificant.

I Physical examination takes a whole patient approachand is based upon the principles of inspection, palpation,percussion and auscultation.

I Undertaking advanced nursing roles is underpinned bythe need for continuing education and experience todevelop competence.

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