It’s important to look at the subjective data – or the patient’s point of view – and objective data – the aspects of a patient that are measurable with examination and tests.
These include inspection – looking at the patient – palpation – feeling the patient – and auscultation – listening to the patient’s heart.
Subjective data allows you to gather the patient’s common or concerning symptoms, including…
Chest pain – Where is the pain? When does it occur? Describe the intensity, type, duration. Does it radiate? Does it come with or without exertion? Any associated symptoms (shortness of breath, sweating, nausea, palpitations or anxiety)? Does anything alleviate or aggravate the pain?
Does the patient have palpitations? Ask if they have a sensation of racing, skipping, fluttering, pounding, or stopping of the heart.
Does the patient have shortness of breath or dyspnea (difficult breathing) – does it occur with lying down and relieved by sitting up? Does it occur when they bend over or when they cough?
Swelling or edema – When is it worse – morning or evening? Does it improve with elevation?
Ask the patient about their history and risk factors, such as personal or family history of…
– Heart disease including hypertension, type 2 diabetes, physical activity, smoking status, diet, and alcohol or drug use.
– Thrombophlebitis, bleeding disorders, or easy bruising
Gather information regarding:
– Patient’s usual activity – such as prolonged standing, walking, or sitting.
– Does the patient experience pain in the legs during activity? numbness/tingling, aching, or cramping? Swelling in legs or feet?
– Has the patient had any skin changes such as redness or pallor, cold skin, visible veins, or lower leg ulcers?
– Elderly patients may complain of chest pain, or they may have less obvious complaints related to a myocardial infarction such as dyspnea, diaphoresis, nausea/vomiting, or syncope.
– Ask the older patient about dizziness, syncope, confusion, or orthostatic hypotension – these symptoms may be related to heart or circulatory changes and indicate a reduced blood supply to the brain.
It is important to gather accurate objective data, including vital signs and height/weight, which will provide valuable information about cardiovascular function.
– Height & weight trends assess fluid and nutritional status. Abrupt weight change will indicate fluid gain or loss. Weight loss over months or years may indicate advancing cardiovascular disease and be a sign of poor nutrition and muscle wasting. Weight should be measured first thing in the morning, after urination but before dressing or eating.
– When checking vital signs, take the blood pressure, pulse, and respirations near the same time. Be sure to use the appropriate blood pressure cuff size – if the cuff is too large, readings will be artificially low; and if the cuff is too small, the readings will be artificially high. If you obtain an abnormal vital sign, recheck it to make sure you’re getting an accurate reading.
Aspects of objective data include inspection. Begin your inspection when you first encounter the patient, looking at:
General appearance - are they thin or obese? What is their level of alertness - anxious, drowsy, or lethargic? What about skin color, turgor, texture, and temperature? Are mucous membranes pale? Do fingers have clubbing or cyanosis?
Observe for pulsations or retractions, and symmetry of movement of the chest wall while the patient is sitting or lying flat. Examine extremities – looking for arterial or venous disorders – noting symmetry, edema, weeping, lesions, scars, and skin color.
Check for jugular vein distention (JVD) by positioning the patient on their back, elevating the head of bed 45 degrees, and turning the patient’s head slightly away from you. Look for a pulsation in the neck that occurs in several waves with each cardiac cycle. If you see a pulsation and are not sure if it’s JVD or the carotid pulse, palpate the radial pulse while watching the neck and if the single pulsation in the neck coincides with the radial pulse, you are seeing the carotid pulse. Normally, the jugular veins are not distended when the head is elevated at 45 degrees.
Palpation is sometimes overlooked, but still an important aspect of the cardiovascular assessment. Palpate the apical impulse, noting the size, location, intensity, amplitude, and duration. It should be a gentle pulsation that coincides with the carotid pulse.
Palpate the patient’s extremities to assess skin temperature, texture, turgor, and edema. Edema is measured on a four-point scale – from 1+ if the finger leaves a slight indention, to a 4+ if the finger leaves a deep imprint that returns to normal very slowly.
Check capillary refill by pressing the nail beds on fingers and toes, and refill time should be 3 seconds or less.
Use the pads of the index and middle fingers to palpate all pulses, including temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis. All pulses should be equal in strength and regular in rhythm.
Auscultation of the heart should be done with the patient in three positions – sitting up, lying on the left side, and lying on the back with the head of bed elevated 30 to 45 degrees. Use a good quality stethoscope with snug-fitting earpieces. Use the diaphragm to hear high-pitched sounds, use the bell, held lightly against the skin, to hear low-pitched sounds. A quiet environment is essential to hear heart sounds and accurately evaluate – so turning off the TV or other background noises may be necessary. Auscultation is best performed directly on bare skin, as clothing can mimic abnormal sounds. Hair on the chest can also cause friction under the stethoscope – this can be minimized by lightly wetting the hair before auscultation. As you listen to the heart over the entire precordium, or anterior chest wall, use a zigzag pattern, starting at the base of the heart and working downward towards the apex.
Normal heart sounds, S1 and S2, are caused by events in the cardiac cycle. As blood flows from the atria to the ventricles, it goes through the tricuspid & bicuspid valves. These valves then snap shut, making the first heart sound (S1) or “lub” in “lub dub.” As these 2 valves snap shut, the pulmonary & aortic valves just opened. This is the beginning of systole, or contraction of the ventricles.
As the ventricles contract, blood is pumped through the pulmonary valve (leading to the lungs) and the aortic valve (leading to the aorta & rest of the body). These valves then snap shut, making the 2nd heart sound (S2) or “dub” in “lub dub.” This is the end of systole & the beginning of diastole.
When listening over the precordium, there are five precordial landmarks where you can best hear sounds from each heart valve. The sites of auscultation are actually not at the exact anatomic site, but the stethoscope is positioned downstream from the flow of blood through the valves. Use the diaphragm of the stethoscope, switching to the bell to hear lower pitched sounds.
The Aortic valve area is on the right side at the 2nd intercostal space (ICS). The next three listening points lie along the left sternal border. The Pulmonic valve area is at the left base of the heart, located in the 2nd ICS. Erb’s point is at the left 3rd ICS, lying halfway between the base and the apex. The Tricuspid valve area is at the left 4th ICS. And the final listening area is at the apex, normally at the left 5th ICS at the midclavicular line, called the Mitral valve area.
You can remember these locations using the mnemonic A-P-E-T-M: All People Enjoy Time Magazine
As you listen at each of these listening points, use the diaphragm and “inch” your stethoscope from one point to the next, so you can track the sounds and concentrate on identifying S1 and S2. To differentiate S1 and S2, concentrate on the rhythm – normally systole is shorter than diastole, so there is a longer pause after S2. S2 is also louder at the base while S1 is louder at the apex. S1 also coincides with the carotid pulse.
Also listen for abnormal heart sounds. In patients with congestive heart failure, you may hear an S3 following S2. An S4 sound is associated with hypertension, coronary artery disease, and often a myocardial infarction. S3 and S4 are low-pitched and better heard using the bell of the stethoscope.
After listening to all points with the diaphragm, use the bell, with very light pressure to listen over the 5 areas again. Blood should be flowing smoothly over the valves. However, if a valves is stenotic, or doesn’t open widely, blood flow will be turbulent, causing a swishing or whooshing sound – this is a murmur. A murmur can also be caused by a valve that is regurgitant or does not close tightly. Murmurs are graded according to their loudness, from grade 1 to grade 6.
If you hear a high-pitched, scratchy sound similar to sandpaper rubbing together, it is likely a pericardial friction rub, in which the pericardium, the membrane surrounding the heart, becomes inflamed. Friction rubs can be heard during systole and diastole and are generally loudest over the apex of the heart.
Listening to heart sounds takes concentration and practice. If you’re having difficulty hearing heart sounds, ask the patient to change position to bring his heart closer to the chest wall. Be sure to reduce background noises and place your stethoscope directly on the chest wall. Don’t hesitate to make adjustments as needed, so that your findings from this crucial assessment are as accurate as possible.