Chapter 2. Patient Assessment
2.8 Head-to-Toe Assessment: Cardiovascular Assessment
Checklist 18 provides a guide for subjective and objective data collection in a cardiovascular assessment.
Checklist 18: Cardiovascular (CV) AssessmentDisclaimer: Always review and follow your agency policy and guidelines regarding this specific skill. |
Safety considerations:
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Objective DataConsider the following observations. |
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Steps
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Additional Information |
| Colour of Skin & Mucous Membranes | Cyanosis (a bluish tinge) may suggest inadequate oxygenation and CV compromise |
| Temperature of Extremities | Hot skin may suggest fever and should be followed up with full vital signs, report to the primary prescriber, and investigation of any suspected sources of infection.
Cold skin may suggest existing or new circulatory related issues. |
| Blood Pressure, Heart Rate, SpO2 | Baseline vital signs are important in any assessment. Vital signs should be compared to the patient’s normal values. Patterns and trends outside of the normal range should be reported to the appropriate person. |
| Capillary Refill | Press on the nail beds of toes and/or fingers until there is blanching (whiteness). Release the pressure and count how many seconds until the patient’s full colour returns.
Delayed cap refill may suggest cardiovascular or respiratory dysfunction and should be followed-up with a focused assessment. |
| Edema | Edema can be the result of many things, including:
It is important to ask the patient if is this normal for them. Observe limbs simultaneously in order to compare. Unilateral edema of the leg may suggest deep vein thrombosis (DVT). Edematous tissue has a high risk of skin breakdown. Implement strategies to maintain skin integrity. |
| Palpate Extremities to Quickly Assess Colour, Warmth, Movement, and Sensation (CWMS), Capillary Refill of Hands and Feet | Colour and warmth provide information about perfusion.
Movement provides a brief overview about musculoskeletal function of extremities, which is affected by circulation. Sensation: by asking if the client has numbness and/or tingling in extremities the nurse gets a brief overview of client baseline. Altered sensation may be the result of impaired neurological function or impaired perfusion. Palpate pulses for symmetry in quality, rate, and rhythm. This provides information about perfusion. Asymmetry in relation to assessment findings may indicate a number of things including cardiovascular conditions, history of injury, or post surgical complications. Report concerns to the appropriate healthcare professional.
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| Auscultate: Apical Heart Rate for Rate and Rhythm | Apical pulses are assessed using a stethoscope placed over the 4th–5th intercostal space of the midclavicular line on the left side on adults. For accuracy, an apical heart rate should be taken for a full minute. Identify S1 and S2 and follow up on any unusual findings. |
| Clubbing of Nails | Clubbing of nails may suggest underlying cardio p