This document provides information on performing a physical examination of the cardiovascular system. It discusses inspection techniques such as observing the patient's appearance, taking pulses and blood pressures, and checking jugular venous pressure. It also covers palpation, percussion and auscultation methods. The purpose is to integrate these examination skills and apply them to accurately assess patients' cardiovascular health and problems.

1. CARDIO VASCULAR SYSTEM:
History taking and physical
examination
By C Settley

2. Upon completion of the unit,
the student will be able to:
• Integrate inspection, palpation, percussion and auscultation techniques and apply it in an examination
of all body systems.
• Apply examination principles and techniques in accordance with health authority guidelines and
established protocols.
• Adapt assessment procedures to the age of the client according to guidelines and protocols.
• Assess client problems accurately in terms of the available information and selected examination
techniques.
• Explain the diagnostic criteria for minor ailments with reference to their meaning and required evidence
in accordance with accepted medical usage and classifications.
• Formulate a diagnosis of minor ailments accurate in terms of the diagnostic criteria for each ailment.
• Implement appropriate diagnostic-, assessment tools and tests in terms of the signs and symptoms
presented and current guidelines and protocols.
• Apply tests, diagnostic and assessment tools correctly in accordance with their purpose and procedures
for use.
• Explain the application of a range of non-pharmacological and pharmacologic interventions and
treatments with reference to their action, effectiveness and related advantages and disadvantages.
• Apply therapies correctly in response to specific diagnoses of minor ailments and according to
treatment protocols and guidelines.
• Determine the effectiveness of treatment through monitoring and assessment at scheduled intervals.
• Identify instances where treatment is not effective and refer to the relevant health professional
according to established procedures.
• Identify complications against protocol and guidelines and refer to appropriate authorities without
delay.
• Identify the scope and limitations of own competence and scope of authority in accordance with the
scope of nursing practice and institutional policies and procedures.
• Refer clients promptly and appropriately in terms of the context, need and availability of expertise when
it is beyond own scope. Ensure that referral complies with existing referral systems.
• Follow treatment guidelines and protocols for managing minor ailments and common illnesses correctly
within organizational constraints.
• Record referrals in accordance with institutional procedures. Records are detailed, and provide an
adequate basis for decision making about subsequent treatment.
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3. CVS –Physical examination
Brunner pg.67
• Inspection
“A conscientious nurse is not necessarily an
observing nurse; and life or death may lie with
the good observer.” This statement by Florence
Nightingale provides inspiration and direction
for inspection, which is usually the first
assessment technique used during the
assessment process. Inspection is an ongoing
process that you use throughout the entire
physical assessment and patient encounter.
Inspection is the use of one’s senses of vision
and smell to consciously observe the patient.
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4. CVS –Physical examination
Brunner pg.67
• Inspection
– Vision
• Use of sight can reveal many facts about a
patient.
• The process of visual inspection necessitates
full exposure of the body part being
inspected, adequate overhead lighting, and,
when necessary, tangential lighting.
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5. CVS –Physical examination
Brunner pg.67
• Inspection
– Smell
• The nurse’s olfactory sense provides vital
information about a patient’s health status.
• The patient may have a fruity breath odour
characteristic of diabetic ketoacidosis.
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6. CVS –Physical examination
Brunner pg.67
• Inspection
– Many clues to the cardiac condition can
be detected with a simple visual
inspection.
– In the acutely unwell patient, cyanosis,
pallor, and sweatiness can all be signs of
impending danger – does the patient
"look" ill?
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7. Facial signs associated
with cardiac conditions
Facial sign Description
Possible cardiac
association
Malar flush Redness around the
cheeks
Mitral stenosis
Xanthomata Yellowish deposits of
lipid around the eyes,
palms, or tendons
Hyperlipidemia
Corneal arcus A ring around the
cornea
Age, hyperlipidemia
Proptosis Forward projection or
displacement of the
eyeball; occurs in
patients with Graves'
disease
Atrial fibrillation
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8. CVS –Physical examination
Brunner pg.67
• Inspection
– Taking the pulse:
• Taking the pulse is one of the simplest, oldest,
and yet most informative of all clinical tests.
• As you pick up the patient's hand, you should
check for clubbing and any peripheral signs of
endocarditis.
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9. Peripheral signs associated
with infective endocarditis
Peripheral sign Description Cardiac association
Clubbing Broadening or
thickening of the tips
of the fingers (and
toes) with increased
lengthwise curvature
of the nail and a
decrease in the angle
normally seen
between the cuticle
and the fingernail
Infective endocarditis,
cyanotic congenital
heart disease
Splinter hemorrhages Streak hemorrhages in
nailbeds
Infective endocarditis
Janeway lesions Macules on the back
of the hand
Infective endocarditis
Osler's nodes Tender nodules in
fingertips
Infective endocarditis
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10. CVS –Physical examination
Brunner pg.67
• Inspection
– Taking the pulse:
• Note the rate and document the rhythm of
the pulse.
• The character and volume of the pulse can
also be useful signs and traditionally it is
believed that these are easier to detect in
larger arteries such as the brachial and the
carotid.
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11. Abnormal pulses
Type of pulse Pulse characteristics Most likely cause
Regularly irregular – 2nd-degree heart block, ventricular bigeminy
Irregularly irregular – Atrial fibrillation, frequent ventricular ectopics
Slow rising Low gradient upstroke Aortic stenosis
Waterhammer, collapsing Steep up and down stroke (lift arm so that wrist is
above heart height)
Aortic regurgitation, patent ductus arteriosus
Bisferiens A double-peaked pulse – the second peak can be
smaller, larger, or the same size as the first
Aortic regurgitation, hypertrophic cardiomyopathy
Pulsus paradoxus An exaggerated fall in pulse volume on inspiration
(>10 mm Hg on sphygmomanometry)
Cardiac tamponade, acute asthma
Bounding Large volume Anemia, hepatic failure, type 2 respiratory failure
(high CO2)
Pulsus alternans Alternating large and small volume pulses Bigeminy
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12. CVS –Physical examination
Brunner pg.67
• Inspection
– Taking the pulse:
• Checking both radials simultaneously is
important in all cases of chest pain as a gross
screening test for aortic dissection.
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14. CVS –Physical examination
Brunner pg.67
• Inspection
– Blood pressure
• Hypertensive heart disease refers to heart
conditions caused by high blood pressure. The
heart working under increased pressure
causes some different heart disorders.
• Hypertensive heart disease includes heart
failure, thickening of the heart muscle,
coronary artery disease, and other conditions.
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15. CVS –Physical examination
Brunner pg.67
• Inspection
– Jugular venous pressure
• If you ever see someone with a bulging neck vein, you’re looking at the
external jugular vein. When the jugular vein is visible, it’s known as jugular
vein distention (JVD).
• Internal and external jugular veins run along the right and left sides of your
neck. They bring blood from your head to the superior vena cava, which is
the largest vein in the upper body. The vena cava runs to your heart,
where blood arrives before passing through your lungs to pick up oxygen.
• JVD is a sign of increased central venous pressure (CVP). That’s a
measurement of the pressure inside the vena cava. CVP indicates how
much blood is flowing back into your heart and how well your heart can
move that blood into your lungs and the rest of your body.
• JVD is a symptom of several different cardiovascular problems. Some of
them can be life-threatening. Contact your doctor right away if you have
JVD.
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16. CVS –Physical examination
Brunner pg.67
• Inspection
– Jugular venous pressure
• JVD occurs when the CVP increases above a normal or healthy
level. This can be caused by several conditions.
• Right-sided heart failure
• Heart failure means the heart has grown too weak to effectively
pump enough blood to meet the demands of the body.
• Right-sided heart failure usually develops after left-sided heart
failure. The left ventricle pumps blood out through the aorta to
most of the body. The right ventricle pumps blood to the lungs.
When the left ventricle’s pumping power weakens, fluid can back
up into the lungs. This eventually weakens the right ventricle.
• When the heart’s right side can’t properly empty, blood can
back up into the veins, causing them to bulge.
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17. CVS –Physical examination
Brunner pg.67
• Inspection
– Jugular venous pressure
• Pulmonary hypertension
• Pulmonary hypertension occurs when the pressure in
the lungs increases, sometimes as a result of changes to
the lining of the artery walls. This can also lead to right-
sided heart failure.
• Tricuspid valve stenosis
• The valve that separates the right atrium and the right
ventricle can become stiff. As a result, it may be unable
to open up enough to let all the blood in the atrium
flow into the ventricle. Blood can back up in the atrium,
causing a backup of blood in the veins, including the
jugular veins.
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18. CVS –Physical examination
Brunner pg.67
• Inspection
– Jugular venous pressure
• Superior vena cava obstruction
• This is a rare condition, usually caused by a tumor
in the chest that restricts blood flow in this large
vein.
• Constrictive pericarditis
• The pericardium is a thin, fluid-filled sac that
surrounds your heart. An infection of the
pericardium, called constrictive pericarditis, can
restrict the volume of the heart. As a result, the
chambers can’t fill with blood properly, so blood
can back up into veins, including the jugular veins.
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19. The jugular vein
The patient is lying at a 45° angle,
thus revealing the surface markings of the neck.
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20. CVS- pg. 619
• Inspection
– Cyanosis
– Pallor
– Oedema
– Clubbing of fingernails
– Distended neck veins
– Enlarged liver and spleen
– Pulse
– Temperature
– Respiration
– Urine output and fluid balance
– Body weight
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21. CVS –Physical examination
Brunner pg.67
• Palpation
• The second assessment technique is palpation, which is the act of
touching a patient in a therapeutic manner to elicit specific
information.
• Prior to palpating a patient, some basic principles need to be
observed.
• You should have short fingernails to avoid hurting the patient as
well as yourself.
• Also, you should warm your hands prior to placing them on the
patient; cold hands can make a patient’s muscles tense, which
can distort assessment findings.
• Encourage the patient to continue to breathe normally
throughout the palpation.
• If pain is experienced during the palpation, discontinue the
palpation immediately.
• Most significantly, inform the patient where, when, and how the
touch will occur, especially when the patient cannot see what
you are doing. In this way, the patient is aware of what to expect
in the assessment process.
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22. CVS –Physical examination
Brunner pg.67
• Palpation
– Your hands are the tools used to perform the palpation
process. Different sections of the hands are best used for
assessing certain areas of the body. The dorsum of the
hand is most sensitive to temperature changes in the body.
Thus, it is more accurate to place the dorsum of the hand
on a patient’s forehead to assess the body temperature
than it is to use the palmar surface of the hand. The palmar
surface of the fingers at the metacarpophalangeal joints,
the ball of the hand, and the ulnar surface of the hand
best discriminate vibrations, such as a cardiac thrill and
fremitus. The finger pads are the portion of the hand used
most frequently in palpation. The finger pads are useful in
assessing fine tactile discrimination, skin moisture, and
texture; the presence of masses, pulsations, edema, and
crepitation; and the shape, size, position, mobility, and
consistency of organs
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23. CVS –Physical examination
Brunner pg.67
• Palpation
– The palm of your right hand is placed
across the patient's left chest so that it
covers the area over the heart.
– The heel should rest along the sternal
border with the extended fingers lying
below the left nipple.
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24. Palpation of the Precordium
to Determine the Location of the PMI
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25. CVS –Physical examination
Brunner pg.67
• Palpation
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26. CVS –Physical examination
Brunner pg.67
• Percussion
– Percussion of the heart involves tapping
on the surface of the body in order to
determine the underlying structure.
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27. CVS –Physical examination
Motlagane pg.621
• Ausculation
– Auscultation is usually performed using a
stethoscope, although louder heart murmurs
and vascular abnormalities can sometimes
be audible without the aid of a stethoscope.
Auscultation of the heart can help gather an
understanding of cardiac rate and rhythm,
condition of the valves, as well as possible
anatomical abnormalities, such as
congenital defects or an underlying chronic
condition.
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28. Auscultation
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29. Auscultation
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30. Cardiovascular exam
• *Video- Cardiovascular exam
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31. General clinical signs
• Subjective data
– Mainly obtained from the patient
• Chest pain
• Pain in the arms/legs
• Dyspnoea
• Dysrhythmias
• Fatigue
• Fluid retention
• nocturia
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32. General clinical signs
Objective data
– Cyanosis
– Pallor
– Oedema
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33. General clinical signs
– Clubbing of fingernails (Clubbing often occurs in heart and lung diseases that
reduce the amount of oxygen in the blood).
– Distended neck veins
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34. General clinical signs
– Enlarged liver/spleen
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35. General clinical signs
– Pulse rate
• Normally between 60 (beats per minute) and 100
(beats per minute)
• Tachycardia
• Bradycardia
– Pulse rhythm & force & volume
• A normal rhythm has the same time interval
between the beats. Volume is the force or strength
of the pulse. Terms used to describe the volume
(force) of the pulse are weak, thready, or feeble
for a pulse that lacks strength, and strong, full, or
bounding for a pulse that feels forceful.
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36. General clinical signs
– Pulse tension
• It corresponds to diastolic blood pressure. A
low tension pulse (pulsus mollis), the vessel is
soft or impalpable between beats.
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37. General clinical signs
– Blood pressure
• If you have heart failure, there's a good
chance you also have high blood pressure, or
"hypertension." About two-thirds of people
whose hearts can't pump enough blood
because of the condition also have high BP or
once did. Hypertension is a major risk factor for
heart failure.
– Temperature
• Indicates circulation
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38. General clinical signs
– Respiration
• Adequate pulmonary circulation is dependent
on healthy lung fields
• Cyanosis
– Urine output and fluid balance
• Indication of circulation
• Excessive output results in fluid overload
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39. General clinical signs
– Body weight
• Weight gain is related to fluid retention or
oedema where cardiac output and venous
return are reduced
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40. LSHF & RSHF
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41. Reference list
• http://www.delmarlearning.com/companions
/content/1401872069/About%20the%20bo
ok/sample%20chapter.pdf
• https://www.ncbi.nlm.nih.gov/books/NBK2213
/table/A13/?report=objectonly
• https://www.healthline.com/health/jvd#caus
es
• http://www.firstaidforfree.com/what-is-
cyanosis/
• http://fudo-puchi.info/nail-clubbing/nail-
clubbing-the-relationship-between-nails-and-
health-osteopathy-singapore-download/
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