1. Cardiovascular Nursing
Assessment

2. Health History Identify present and potential health problems
Identify possible familial and lifestyle risk factors
Involve the client in planning long-term health care

3. Health History High Blood Pressure Congestive Heart Failure
Patient Health History should be obtained:
High Blood Pressure
Congestive Heart Failure
Previous Heart Attack
Previous Heart Surgery or procedures (Stent, Valvuloplasty)
Atrial Fibrillation, Atrial Flutter or other dysrhythmias
Palpitations
Dizziness, lightheadedness (presyncope), or passing out (syncope)
Full list of medications
Family hx.

4. Cardiovascular Assessment
Requires a full head to toe assessment
Every body function is dependant on the cardiovascular system
Subjective vs. Objective data
Subjective data- verbal statements provided by the patient
Objective data- observable and measurable data

5. Signs & Symptoms of Cardiovascular Deficits
Chest Pain
Palpitations
Cyanosis
Dyspnea

6. Assessment Subjective Data
Pain is whatever the patient says it is.
Pain (chest, back, jaw, abdomen or extremities)

7. Assessment- Subjective Data
Extremities
3 of the 5 “P’s of Peripheral Artery Disease”
Pain
Parasthesia
Alteration in sensation
Numbness, tingling, pins and needles
Paralysis

8. Assessment Subjective Data
Dyspnea
At rest
Exertional- with activity
Orthopnea- short of breath while lying down
Paroxysmal Nocturnal Dyspnea- awakening suddenly short of breath and sweating

9. Assessment Subjective Data
Ask pt. to: Describe Chest Pain (CP) or Shortness of Breath (SOB) in as much detail as possible.

10. Assessment Subjective Data
Is patient c/o:
Fainting (Syncope)
Palpitations
Fatigue

11. Assessment - Objective Data
Head to Toe Assessment
Skin
Cyanosis
Turgor
Temperature
Diaphoresis
Integrity
Skin breakdown

12. Jugular Vein Distention JVD

13. JVD
ABNORMAL
NORMAL

14. Cardiac Assessment
Heart Sounds (listen with both the bell and diaphragm of your stethoscope)
Right upper sternal border, Left upper sternal border, Left lower sternal border

15. Assessment- Objective Data
Are there any abnormal heart sounds?
Murmurs
Rubs
Are there any additional heart sounds?
Gallops
Is the heartbeat regular, regularly irregular, or irregularly irregular?

16. Assessment - Objective Data

17. Assessment Objective Data
Respiratory
Rate and ease of breathing
Appearance of dyspnea
Coughing
Frothy Sputum
Abnormal breath sounds
Diminished
Crackles/Rales
Wheezing

18. Assessment - Objective Data
Post tibial Pulses
Dorsalis pedis Pulses
Popliteal pulses
Femoral pulses
Ulnar pulses
Radial pulses
Brachial pulses
Carotid pulses

19. Assessment Objective Data
Check Pulses:
Carotid Right/ Left
Brachial R/L
Radial R/L
Ulnar R/L
Point of Maximum Impulse (PMI)
Femoral R/L (groin crease or slightly above crease)
Popliteal (behind the knee)
Post Tibial (medial ankle)
Dorsalis Pedis (top of foot)
Pulse Strength
0 Absent pulse
1+ Thready pulse
2+ Weak pulse
3+ Normal pulse
4+ Bounding pulse OR
0 Absent Pulse
1+ Weak Pulse
2+ Normal Pulse

20. Assessment Objective Data
Edema
1+ trace edema-barely perceptible (2mm)
2+mild edema-deeper pit that rebounds in seconds (4mm)
3+moderate edema-deep pit that lasts seconds before it rebounds (6mm)
4+severe edema-an even deeper pit lasting as long as 2-5 minutes before rebounding (8 mm)

21. Assessment Objective Data
Check for Homan’s sign Pain=Positive Homan’s Sign
If Positive: Notify RN or Practitioner and do not check Homan’s Sign Again!
Capillary Refill of finger tips and toes (actually any area)
Normal: < 3 seconds
Slow: 3-5 seconds
Abnormal: >5 seconds

22. Assessment Objective Data
Allen’s Test
Tests the ability of the ulnar artery to supply the hand with adequate blood supply

23. Assessment Objective Data
Vital Signs
Heart Rate (full minute) Normal bpm
Apical Pulse
Radial Pulse
Pulse deficit is the difference between the above two
Blood Pressure Normal /60-89 mmHg
Mean Arterial Pressure (MAP)
(2 * DBP) + SBP 3

24. Blood Pressure
No sound
BP cuff inflated to 160 mmHg
120 mmHg
First sound
50 mmHg
No sound
Korotkoff sounds: heard during blood pressure determination using a stethoscope and sphygmomanometer.
Originates within from the blood passing through the vessel or
Produced by a vibrating motion of the arterial wall

25. Orthostatic Hypotension aka Postural Hypotension
Have the client in supine position for 3-5 minutes, then measure the HR and BP
Then, have the client in the sitting position for 3-5 minutes and then measure the HR and BP. Monitor for dizziness.
Then, have the client stand for 3-5 minutes. If the client is having severe dizziness, STOP! (if they have a syncopal episode, they are at risk for injury). Otherwise, measure the HR and BP after 3-5 minutes.

26. Orthostatic Hypotension
A client is considered to have orthostatic hypotension if:
HR increases by 10-20% from baseline
SBP decreases by mmHg from baseline
DBP decreases by 10 mmHg from baseline