Assessing the Cardiovascular and

Peripheral Vascular Systems

The

cardiovascular/circulatory
system transports -to and from
cells.

ANATOMY AND PHYSIOLOGY

Cardiovascular Anatomy &

Physiology
Cone
top
bottom
Heart

size =
Precordium=

Interesting facts...
The

heart does not rest for more than a fraction of

a second at a time
During a lifetime it contracts more than 4 billion
times
Coronary arteries supply more than 10 million
liters of blood to the myocardium in a lifetime

Interesting facts.
Cardiac

output (heart rate X stroke volume) can

vary under physiologic conditions from 3 to 30
liters/minute

Remember:

Normal cardiac output for adults is

5-6 liters/minute

Common Diseases of the Heart

Coronary

artery disease
Hypertension
Rheumatic heart disease
Bacterial endocarditis
Congenital heart disease
Congestive Heart Failure
Cardiomyopathy
Arrhythmias

Components of the circulatory system

Blood
Blood

vessels: vascular system,arteries, veins,

capillaries
Heart

Structure of the Cardiovascular

system

Blood circulation

Topographical Landmarks of the

Heart

Topographical Landmarks

Aortic area
Pulmonic area
Tricuspid
Mitral

Topographical Landmarks

Aortic area - 2nd ICS to right of sternum

(closure of the aortic valve loudest here).

Topographical Landmarks

Pulmonic area - 2nd ICS to left of sternum

(closure of the pulmonic valve loudest
here).

Topographical Landmarks

Tricuspid - 5th ICS left of sternal border

(closure of tricuspid valve).

Topographical Landmarks

Mitral - 5th ICS left of the sternum just medial to

MCL (closure of mitral valve).
When cardiac output is increased as in anemia,
anxiety, HTN, fever, the impulse may have
greater force

Cardiovascular: Blood Flow

Deoxygenated Blood:
Superior Vena Cava
& Inferior Vena Cava
R Atrium
Tricuspid valve
R Ventricle
Pulmonic Valve
Pulmonary Artery to lungs (gets
oxygenated)

Oxygenated Blood:
Pulmonary veins
L Atrium
Mitral Valve
L Ventricle
Aortic Valve
Aorta
Body

Cardiovascular: Blood Supply

There

are two main coronary arteries, the left

(LCA) and the right (RCA)
Coronary artery blood flow to the myocardium
occurs primarily during diastole
To maintain adequate blood flow through the
coronary arteries, the diastolic pressure must be at
least 60 mmHg.

Cardiovascular: Cardiac Cycle

2

phases
DIASTOLE: AV valves open passive flow (75% of
volume) into relaxed ventricles, then atria contract
active flow of remaining 25% into ventricles
SYSTOLE : AV valves close, ventricle pressure
increases, ventricle contracts, Seminular valves open,
blood pumped into pulmonary and systemic arteries

Cardiovascular: Heart Sounds

Heart

sounds: lub dub

SYSTOLE: lub= S1 (closing of AV valves)
DIASTOLE: dub = S2 (closing of semilunar valves)
During the cardiac cycle, valves are opening and
closing, causing different heart sounds (S1 and S2).
Sometimes abnormal heart sounds are heard due to
improper opening or closing of the valves.(murmurs)

Cardiovascular: Conduction
Heart contracts by itself through its own conduction
system:
Sinoatrial (SA)node (pacemaker) initiates
electrical impulse
AV node
Bundle of HIS (L & R Bundle Bbranches)
Purkinje fibers

The sinoatrial (SA) node, located within the

right atrial wall near the opening of the
superior vena cava

The atrioventricular (AV) node, also located

within the right atrium but near the lower end
of the septum

The atrioventricular bundle (bundle of His),

which extends from the atrioventricular node
along each side of the interventricular septum

Purkinje fibers, which extend from the

atrioventricular bundle into the walls of the
ventricles. The electric impulses from this
conduction system can be recorded on an
electrocardiogram.

Conduction System

Electrocardiography (ECG)
records

the electrical impulses generated from the

heart muscle and provides a graphic illustration of
the summation of these impulses and their
sequence and magnitude.

Cardiovascular: Conduction
Electrical

impulses shown on ECG

PQRST wave correlates to impulses traveling
through the heart.
SA to AV = P wave, (atrial stimulation)
Stimulus spreads through bundle of His = QRS
complex
Repolarization of ventricles =T wave

The ECG waves

P

wave represents the electric activity associated

with the sinoatrial node and the spread of the
impulse over the atria. It is a wave of
depolarization.

The ECG waves

QRS

complex (wave) is composed of three separate

waves:
the Q wave, the R wave, and the S wave.
They are all caused by currents generated when the
ventricles depolarize before their contraction.
Because ventricular depolarization requires septal and
right and left ventricular depolarization, the electrical
wave depicting these events is more complex than the
smooth P wave.

The ECG waves

P-R

interval is measured from the beginning of

the P wave to the beginning of the QRS complex.
It is termed P-R instead of PQ because frequently
the Q wave is absent.
This interval represents the time that elapses from
the begin Q-T intervalning of atrial depolarization
to the beginning of ventricular depolarization.

The ECG waves

The

T wave represents repolarization of the ventricles.

The Q-T interval begins with the QRS complex and ends
with the completion of the T wave.
It
represents
ventricular
depolarization
and
repolarization.
This interval varies with the heart rate.
The faster the rate, the shorter the Q-T interval. Therefore
in children this interval is normally shorter than in adults.

The ECG waves

The

S-T segment is normally an isoelectric (flat)

line that connects the end of the S wave to the
beginning of the T wave.

The ECG waves

The

T-P interval represents atrial and ventricular

polarization in anticipation of the next cardiac
cycle.

Cardiovascular:Pumping Ability
Cardiac

Output (C.O.) = volume of blood in liters

ejected by the heart each minute.
Adult = 4-6 liters/minute
CO = HR x SV
Heart Rate (HR) = number of times ventricles
contract each minute.
Stroke Volume (SV) = The amount of blood ejected
by the left ventricle during each systole.

 Preload

= degree of stretch of myocardial fibers at

end of DIASTOLE. The more the heart is filled
(within limits, i.e., not over-filled), the more
forcefully it contracts.
Afterload = pressure or resistance the ventricles
must overcome to pump out blood. The amount
of resistance is directly related to arterial blood
pressure and the diameter of the vessels.

HEALTH HISTORY

Subjective
Personal

and family history

Diet history: 24 hr. sample diet Opportunity for
teaching food selection and preparation
Socioeconomic status ability to purchase proper
foods, medicines. Employment and its effects on
health?
Cigarette smoking : # packs /day and also # years
smoked

Assessment: Subjective
Physical

Activity/Inactivity 30 minutes daily of

moderate exercise recommended on most days
( Healthy People 2010 )
Obesity associated with HTN, hyperlipidemia,
and diabetes and all contribute to CV disease.
Current Health Problems describe health
concerns.

Past Medical History

Rheumatic

fever
Previous cardiac investigations
Previous myocardial infarction
Coronary angioplasty + stent insertion
Coronary artery bypass grafting
Pacemaker insertion

Medications
Anti-anginal

agents
Antihypertensive agents
Anti-arrhythmics
Platelet inhibitors, e.g., Aspirin
Anticoagulants, e.g., Warfarin
Allergies

Social History
Occupation

e.g., train driver, long distance truck driver

Alcohol

intake
Stairs at home

Family History
Ischaemic

heart disease

Angina
MI
CABG

Hypertrophic

obstructive cardiomyopathy
Dilated cardiomyopathy

Additional history
For

infants: mothers health during pregnancy,

feeding habits, growth, activity.

For

children: growth, activity, any joint pains or

unexplained fever, frequent headaches or nose
bleedings, streptococcal infection (tonsillitis).

Additional history
For

pregnant female: any high BP during this or

previous pregnancies, associated signs (weight gain,
proteinuria), dizziness.

For

aging adult: any symptoms of heart diseases

(HTN, CAD) or COPD, any recent changes,
medications (digitalis), side effects; environment.

Chest Pain
This

is the most important symptom of cardiac

disease
Pain could be from pulmonary, intestinal,
gallbladder, or musculoskeletal sources but it may
be from the heart itself
Every complaint of chest pain must be taken very
seriously!

 Chest

pain: or discomfort, a symptom of cardiac

disease, can result from ischemic heart disease,
pericarditis and aortic dissection.

Chest

pain: can also be due to non- cardiac

causes; pleurisy, pulmonary embolus, hiatal
hernia, anxiety musculoskeletal strain, GERD

Assessment- Chest Pain

Onset
Duration
Frequency
Precipitating factors / Relieving factors
Location
Radiation
Quality
Intensity
Associated symptoms

Causes of Chest Pain

Cardiovascular

Angina
Stable
Unstable

Chest wall

Pleuropericardial

Pericarditis
Pleurisy
Pneumothorax

Myocardial infarction
Aortic dissection
Myocarditis

Gastrointestinal

Gastro-oesophageal reflux
Oesophageal spasm

Coughing
Intercostal muscle
strain/myositis
Herpes zoster
Viral pleurodynia
Thoracic radiculopathy
Rib fracture
Rib tumour
Costochondritis

Characteristics:
Usually

substernal
Radiation chest, shoulders, neck,
jaw, arms
Deep, visceral (pressure) intense
Duration- min. (5-15 min.)

 Associated

with nausea, vomiting, pallor

Precipitated by exercise & emotion
Becomes Unstable when occurs during sleep, at
rest, or increases in severity/frequency
Relief with rest

Subjective data
Cough:

duration, frequency, type, sputum (color,

odor, blood tinged, aggravating and/or relieving
factors.
Cyanosis or pallor: occurs with myocardial
infarction or low cardiac output.
Hemoptysis is often a pulmonary problem, but
also occurs with mitral stenosis

Assessment: Subjective
Weight

gain- a sudden increase in wt. of 2.2

pounds (1 kg) can be result of accumulation of
fluid (1L) in interstitial spaces, known as edema.

Orthopnea

Is the need to assume a more upright

position to breathe.
Note the exact number of pillows used.

Dyspnea on Exertion (DOE)

This

is usually due to chronic CHF or severe

pulmonary disease
Quantify the severity by asking, How many level
blocks can you walk before you get short of
breath?
How many could you walk six months ago?

 Dyspnea:

Cause, onset, duration, affection by position,

Does shortness of breath interfere with activities of
daily living?
Paroxysmal nocturnal dyspnea (PND) occurs with heart
failure.
Classically, the person awakens after 2 hrs. of sleep, arises,
and flings open the window with the perception of needing
fresh air.

SYNCOPE

Syncope
transient

loss of consciousness, decrease in

perfusion to brain.

Fainting

Common Causes of Syncope

Cardiac
Neurocardiogenic
Orthostatic

Hypotension

Metabolic
Neurologic
Psychogenic

Fatigue
Fatigue-

resulting from decreased cardiac output is

usually worse in evening.
Ask pt. if they can perform same activities as a year
ago
A common complaint from people with CHF and
mitral valve disorder
Not at all specific to heart disease, but consider it

Common Causes of Fatique

Cardiac
Anxiety/Depression
Anemia
Chronic

Diseases

Dependent Edema
When

peripheral venous pressure is high, fluid

leaks out from the veins into tissues
This is often the presenting symptom of right
ventricular failure
Edema will begin in legs and gets worse as the day
progresses.
Least evident in the morning after sleeping with the
legs flat, worse as gravity pulls fluid to legs.

Ask These Questions about Dependent

Edema
When

did you first notice the swelling?

Do both legs swell equally?
Did the swelling appear suddenly?
What time of the day is it worse?
Does it disappear after sleeping?
Does propping your legs up make it go away?

More Questions about Edema...

What

medicines do you take now?

Do you have any kidney, heart, or liver disease?
Do you have shortness of breath? Pain in your
legs? Ulcers on your legs?
Have you noticed a difference in how your
clothes fit, especially around the waist?

Physical Exam for Edema

Press

fingers into the dependent areas for 2-3

seconds.
If pitting is present, the fingers will sink into the
tissue and when fingers are removed, the
impression of the fingers will remain

PALPITATIONS

Palpitations
Palpitations-

fluttering or unpleasant awareness of

heartbeat. Non- cardiac- causes- fatigue, caffeine,
nicotine, alcohol
The uncomfortable sensations in the chest
associated with a range of arrhythmias.
Patients may describe palpitations as fluttering,
skipped beats, pounding, jumping, stopping, or
irregularity

ASSESSMENT ARTICLES:
Stethoscope
A Blood

Pressure Cuff
A Moveable Light Source or Pen Light
Sphygmomanometer
Measure tape
Wrist watch and pen

INSPECTION
SKIN, EYES
NECK
PRECORDIUM
EXTREMITIES

Assessment:Objective
Beginning Inspection
General

appearance: Build, skin color

Older age?
Transcultural considerations?
Skin- color and temperature look for symmetry in color,
temp, any cyanosis?
Extremities assess skin changes, vascular changes,
clubbing, capillary filling and edema.
Neck vein distention?
Orhtopnea

Physical Assessment
Inspection-

side to side, at right angle and downward

over precordium where vibrations are visible.
Point of Maximal Impulse (PMI) Apical Impulse
located at 5th intercostal (IC) space at midclavicular
line (MCL) mitral area
Right Ventricular (RV area)
Epigastric area
Pulmonic area

Assessment:Objective
BP:

supine change position 1-2 minutes, check again.

Normally, systolic drops slightly or remains unchanged
and diastolic increases slightly.
Carotid & Peripheral pulses are assessed for:
Presence
Amplitude
Rhythm
Rate
Equality

Assessment:Objective
Precordium Assessment- area over heart, done by:
Inspection
Palpation
Percussion-selective
Auscultation

Eyes
The

presence
of
yellowish plaques on
the
eyelids
(xanthelasma)
-hyperlipoproteinemia
, a risk factor for
hypertension as well
as arteriolosclerosis.

Chest
Observe

the chest for

overall torso contour.
Do you see pectus
excavatum (caved-in
chest)?
Do you see pectus
carinatum
(pigeon
chest)?

Skin
Clubbing-broadening of
the extremities of the
digits-chronic
poor
oxygen perfusion to the
distal tissues of the hand
and feet.

Cyanosis
The

presence
of
cyanosis
(bluish
colour) also denotes
chronic poor oxygen
delivery
to
the
peripheral tissues of
the hands and feet.

Edema

INSPECTING THE NECK

Findings

of neck vein distention

INSPECTING THE PRECORDIUM

aortic,

pulmonic, tricuspid, and apical areas, and

Erbs point) for visible pulsations.
Pulsations usually are absent except for the apical
impulse
Inspect the epigastric area at the tip of the
sternum for pulsation of the abdominal aorta.

INSPECTING THE EXTREMITIES

color,

temperature,
continuity,
(integument), venous patterns, and
varicosities, rashes, ulcers.

Phlebitis

(inflammation of a vein)

lesions
edema,

Palpation

Physical Assessment
to

detect any precordial motion or thrills.

Palpate apical impulse

Palpation
Palpate

the apical impulse (the point of maximal

impulse, or PMI):

Location: intercostal space (usually 5th ICS) at left MCL,

Size: normally 1 cm 2 cm,
Amplitude: normally a shot, gentle tap,
Duration: short, normally occupies only first half of
systole.
Ask the client to exhale then hold it or turn him to the
left side.

Point of Maximal Impulse (PMI)

Stand

on the right side of the patient with him

sitting.
PMI is usually within 10 cm of the midsternal line
and no larger than 2-3 cm diameter
PMI that is lateral or displaced suggests
cardiomegaly

PMI, cont
About

70% of the time you will be able to feel

PMI with patient sitting.
A PMI that is over 3 cm diameter indicates left
ventricular hypertrophy and
is 86% predictive of increased left ventricular end
diastolic pressure

General Motion
Palpate

all 4 cardiac areas

Any condition that increases the rate of
ventricular filling can produce a palpable impulse

Palpate the peripheral arteries.

brachial, radial, femoral, popliteal, dorsalis pedis,
and posterior tibial.

Palpation

Normal findings
no pulsation palpable
over the aortic and
pulmonic areas,
palpable apical
impulse.

Abnormal findings
precordial thrills, which are
fine,
palpable,
rushing
vibrations over the right or left
second intercostal space, and
lifts
or heaves, which
involve a rise along the border
of the sternum with each
heartbeat.

Abnormal findings
absent,

weak, thready -decreased cardiac output,

a forceful or bounding pulse -hypertension and
circulatory fluid overload,
asymmetric pulse -impaired circulation.
Other specific assessments to determine arterial
blood flow include
Allens test, Buergers test, and capillary refill

PERCUSSION

Percussion
Not

helpful in CV assessment
CXR shows heart size and borders very
accurately
Is used to estimate approximately heart borders
and configuration.
Helps to detect heart enlargement

Chest percussion:
Normally

only the left border of heart can be

detected by percussion.
It extends from the sternum to mid clavicular line
in the third to fifth inter costal space.
The right border lies under the right margin of the

AUSCULTATION
rate,
rhythm,
pitch,
and splitting.

General Principles of Auscultation

Close

your eyes when listening

Never listen through any kind of clothing
Listen all cardiac areas:

Auscultation
A Z-pattern

is recommended.
Before beginning alert the person for long duration
of procedure.
Begin with diaphragm endpiece

Note the rate

the rhythm
Identify S1 and S2
Listen for extra heart sounds
Listen for murmurs

Auscultation

AUSCULTATING HEART SOUNDS

Caused

by closure of the heart valves.

Ask the patient to breathe normally.
beginning at the aortic area,
moving to the pulmonic area,
then to Erbs point, then to the tricuspid area, and
finally to the mitral area
diaphragm of the stethoscope - high-pitched sounds.
bell to listen to lowpitched sounds. -repeat

APE TO MAN
Aortic
Pulmonic
Erbs point
To tricuspid
Mitral

ASSESS Heart Rate.

Count

the number of heartbeats (S1 and S2) heard

for 1 minute for the apical rate.

Normal Heart Sounds

the

first heart sound-S1, lub

This sound occurs when the mitral and tricuspid
valves close and
corresponds to the onset of ventricular contraction
(see figure).
The sound, low-pitched and dull,
heard best at the apical area.

 second

heart sound, S2, dub

occurs at the termination of systole and
corresponds to the onset of ventricular diastole.
represents the closure of the aortic and pulmonic
valves.
S2 is higher pitched and shorter than S1.

 The

two sounds occur within 1 second or less,

depending on the heart rate.
Normally ,
S1 that is louder at the tricuspid and apical areas,
with S2 louder at the aortic and pulmonic areas.

Auscultation (cont.)
S1 and S2

Location and amplitude,

Correlation with peripheral pulses, PMI
Correlation with ECG waves
Lub or dub

ASSESS Rhythm
When

listening to each heartbeat, notice the

spacing between beats.
Normally the heart rate is regular (i.e., an equal
space between beats).

ASSESS Pitch
Note

the pitch of the heart sounds.

Pitch is the quality of the sound dependent on the
relative speed of the vibrations by which it is
produced.
The first and second heart sounds have low and
high pitches, respectively

ASSESS Splitting
Notice

whether there is one sound or two for each

S1 and S2 sound.
Although the closing of two valves creates each
heart sound, you should hear only one sound
indicating that the valves are closing at the same
time.

Abnormal Heart Sounds

extra

heart sounds at any of the cardiac landmarks

and
abnormal rate or rhythm.
S3,
S4,
murmurs,
bruits.

 Anemia,
heart

disease,
serious infections,
diseases of the heart muscle
diseases of the conducting system
dehydration or overhydration,
endocrine disorders,
respiratory disorders, and
head trauma

S3 and S4
S3,

- third heart sound,

lub-dub-dee pattern
best heard with the stethoscope bell at the mitral
area, with the patient lying on the left side.
normal in children and young adults - innocent
heart murmurs
abnormal in middle-aged and older adults.

 S4

- fourth heart sound,

dee-lub-dub.
normal in older adults but
abnormal in children and adults.

Summation Gallop
A summation

gallop is produced when S3 & S4

merge into one sound.
It often occurs at rates greater than 100 beats per
minute.
heart failure and pericarditis.

Heart murmurs
are

extra heart sounds caused by some disruption

of blood flow through the heart.

The characteristics of a murmur depend on

adequacy of valve function,
rate of blood flow, and
size of the valve opening.

ABNORMAL FINDINGS
When

the mitral and tricuspid valves do not close

at the same time,
S1 sound - split into two sounds instead of one.
Splitting is
Systolic Murmur
Diastolic Murmur

 Systolic

Murmur
A murmur occurring
during the ventricular
ejection phase of the
cardiac cycle is
termed a systolic
murmur.

Diastolic

Murmur
A murmur occurring
in the filling phase of
the cardiac cycle is
termed a diastolic
murmur.

 Systolic

Murmur
caused by obstruction
of the outflow of the
semilunar valves or by
incompetent
atrioventricular

Diastolic

Murmur
Incompetent
semilunar valves or
stenotic AV valves.

 Systolic

Murmur
structural deformities of
the aorta or pulmonary
arteries,
anemia, and
Thyrotoxicosis
(hyperthyroidism).
Ventricular septal defect

Diastolic

Murmur
stenosed mitral and
tricuspid valves

Timing of murmurs

Grading of heart murmurs:

Bruits
are

abnormal sounds, are swooshing sounds

similar to murmurs
heard over major blood vessels.
The sound indicates a partially blocked artery
commonly heard over the carotid arteries, the
abdominal aorta, and the femoral arteries.

 The

opening snap caused by the opening of the

mitral or tricuspid valves is another abnormal
sound heard in diastole when either valve is
thickened, stenotic, or deformed.

The

sounds are high pitched and occur early in

diastole.

 In

systole ejection clicks may be heard if either the

aortic or pulmonic valve is stenotic or deformed.
The aortic valve ejection click is heard at either the
apex or base of the heart and does not change with
respiration.
The less common pulmonic valve ejection click is
heard over the second or third left intercostal space.
It increases with expiration and decreases with
inspiration.

 Pericardial

friction rubs are caused by

inflammation of the layers of the pericardial sac.
A rubbing sound is usually present in both
diastole and systole and is best heard over the
apical area.

Normal Age-Related Variations

INFANT/CHILD
Visible cardiac pulsation, if the chest wall is thin
Sinus dysrhythmia (the rate increases with
inspiration and decreases with expiration)
Presence of S3 (in about one third of all children)
More rapid heart rate (until about 8 years of age)

OLDER ADULT
Difficult-to-palpate apical pulse
Difficult-to-palpate distal arteries
Dilated proximal arteries
More prominent and tortuous blood vessels; varicosities
common
Increased systolic and diastolic blood pressure
Widening pulse pressure

Peripheral Vascular System

Peripheral Vascular System

Arteries,

capillaries, and veins provide blood flow to and

from tissues.
arteries and their smaller branches, the arterioles-maintain blood pressure
The veins and their smaller branches, the venules, -act as
a reservoir for extra blood, if needed, to decrease the
workload on the heart.
Pressure within the veins is low compared with arterial
circulation.

 Chest

Pain
Shortness of Breath
Cough
Urinating During the Night
Fainting
Fatigue
Swelling of Extremities
Leg Cramps or Pain

 PALPATE the temporal and carotid pulses.

INSPECT the jugular vein.
MEASURE blood pressure.
INSPECT and PALPATE the upper extremities.
PALPATE upper-extremity pulses.
INSPECT and PALPATE the lower extremities.
PALPATE lower-extremity pulses.

 AUSCULTATE the carotid arteries.

ESTIMATE jugular venous pressure.
PALPATE the epitrochlear lymph nodes.
PALPATE the lower extremities.
PALPATE the inguinal lymph nodes.
ASSESS for varicose veins.

 PALPATE

temporal and carotid pulses for

amplitude.
Tenderness

arteritis.

and edema may be found in temporal

 INSPECT

the jugular vein for pulsations.

right atrial pressure.
Observe for pulsations
Findings: Pulsations of the vein are visible, but not
the vein itself.
Note any fluttering or oscillating of the pulsations.
Note irregular rhythms unusually prominent waves
may indicate right-sided heart failure.

MEASURE blood pressure.

The pressure should not vary more than 5 to 10 mm Hg
systolic between the two arms
Note elevated systolic or diastolic pressures (hypertension)
and
Lowered systolic or diastolic pressures (hypotension).
A decrease BP-fluid volume deficit, drugs (e.g.,
antihypertensives), or prolonged bed rest.
Also note significant discrepancies in measurements
between the two arms.

 INSPECT

and PALPATE the upper extremities

for symmetry and skin turgor.
Findings: The arms should appear symmetric.
Skin turgor should be elastic
Asymmetric upper extremities are abnormal.

INSPECT and PALPATE the upper extremities for

skin integrity,
color, and
temperature;
capillary refill; and
color and angle of the nail beds.

 Findings:
The

skin should be intact, with color appropriate

for race.
The skin should feel warm bilaterally.
Capillary refill should be 2 seconds or less.
Nail beds should be pink, with an angle of 160
degrees at the nail bed

 Thickening

skin, skin tears, and ulceration are

abnormal findings.
Note pallor
A capillary refill time greater than 2 seconds
indicates poor perfusion.
Clubbing of fingers indicates chronic hypoxemia

PALPATE brachial and radial pulses for

rate,
rhythm,
amplitude, and
contour.
When indicated, palpate ulnar pulses.

 INSPECT

and PALPATE the lower extremities

for
symmetry
skin turgor.
comparing the size and proportion.
Pinch an area of the skin
Findings: Legs should appear symmetric.
Skin turgor should be elastic

INSPECT and PALPATE the lower extremities for

skin integrity,
color,
and temperature;
capillary refill;
hair distribution;
color and
angle of nail beds;
superficial veins; and gross sensation.

 same

procedures as upper extremities for assessment

observe for superficial veins that appear dilated.
Palpate the legs lightly for tenderness or numbness.

Findings: The skin should be intact,

color appropriate for race.
The skin should feel warm.
Capillary refill should be 2 seconds or less.
Nails should be pink-160 degrees at the nail bed.
hair evenly distributed on upper and lower legs.
Veins should not be visible.
Sensation of the legs should be present without
tenderness or numbness.

 Compare

the measurements of each leg.

Findings:
Measurements should be similar.
Impaired venous blood flow -edema
increase in thigh circumference-first sign of deep
vein thrombosis.

PALPATE
femoral,
popliteal,
posterior tibial, and
dorsalis pedis pulses for amplitude.

 AUSCULTATE

the carotid artery for bruits.

history of atherosclerosis or dizziness or syncope.

 ESTIMATE

jugular

venous

pressure

for

pulsations.
Jugular venous pressure estimates the pressure in the
right side of the heart.
Estimate this pressure when the patient has fluid
retention or right-sided heart failure
This pressure should not rise more than 1 inch (2.5
cm) above the sternal angle.

 PALPATE

epitrochlear lymph nodes for

size,
consistency,
mobility,
borders,
tenderness,
warmth.

and

 palpated

when the patient has an acute infection of

the ulnar aspect of the arm or a malignancy such as
non-Hodgkins lymphoma.

 PALPATE

inguinal lymph nodes for

size,
consistency,
mobility,
borders,
tenderness,
warmth.

and

 Palpate

these nodes when an inflammatory process

is suspected or the patient complains of pain.
NAVEL: N, nerve; A, artery; V, vein; E, empty
space; L, lymph nodes. Compare the sizes of the
upper and lower legs for symmetry.
Findings: The inguinal nodes are small, mobile
nodes, some of which may be nontender.
The upper and lower legs should be symmetric.

 MEASURE

symmetry.

leg

circumferences

to

assess

 CALCULATE

the ankle brachial index (ABI)

to estimate arterial occlusion.
peripheral arterial disease.
ankle systolic pressure
---------------------------0.95 to 1.2.
brachial systolic pressure.

 PERFORM

Trendelenburgs test to evaluate

competence of venous valves.
varicose veins.

Common Problems and Conditions

Cardiac

Disorders
Valvular Heart Disease
Angina Pectoris
Acute Coronary
Syndrome
Myocardial Infarction
Heart Failure

Infective

Endocarditis
Pericarditis

Peripheral Vascular Disease

Hypertension
Venous

Thrombosis

and
Thrombophlebitis
Aneurysm

Case Study
Mr.

Tao is a 56-year-old man complaining of

difficulty breathing.

 Interview

Data
Mr. Tao does not know exactly when his breathing
difficulty started, but it has gotten noticeably worse
the last couple of days.
His father died of a heart attack at age 60.
Mr. Tao plays golf twice a week;
however, he tells the nurse that this last week he has
just felt too tired to do anything.

 Interview

Data
He says that he has not been able to sleep very well
at night because of his breathing difficulty.
He denies taking any medications.
He says that he does not smoke or drink alcoholic
beverages.

 Examination

Data
General survey:
Alert, anxious,
cooperative,
well-groomed male.
Appears stated age.
Breathing labored.

 Examination

Data

Vital signs:
BP, 142/112 mm Hg, right arm;
144/110 mm Hg, left arm;
temperature, 98.8 F (37.1 C);
pulse, 120 beats/min;
respiration, 26 breaths/min.

 Examination

Data
Pulses: All pulses palpable .
No carotid bruits bilaterally.
Neck: Jugular distention and
pulsation noted with patient in supine position.

 Examination

Data
Lower extremities:
Skin warm and dry, without cyanosis.
Even hair distribution.
2+ pitting edema noted bilaterally.
No lesions present.

 Clinical

Reasoning
1. Which data deviate from normal findings, suggesting a
need for further investigation?
2. For which additional information should the nurse ask or
assess?
3. Based on these data, which risk factors for coronary artery
disease does Mr. Tao have?
4. With which health care team member would you
collaborate to meet this patients needs?