Being a Registered nurse myself I know how important it is to perform a complete and thorough cardiac assessment on your patient. With the number of patients with cardiac disease increasing daily it is essential that you know this important process. Sadly, cardiovascular disease is the leading cause of mortality and morbidity among men and women in the US. The cardiovascular system brings life-sustaining oxygen and nutrients to the body therefore it is important to make sure it is functioning at its best. While in nursing school, we learn all the important steps in completing this process, but the details and steps of the cardiac assessment are easy to forget. Some important tools in performing a cardiac assessment include a stethoscope with a bell and a diaphragm, blood pressure cuff, a ruler, and a penlight. The positioning of your patient is also pertinent, have your patient lie on his back with the head of the bed or examination table at a 30 to 45 degree angle. Keeping a relaxed and friendly manner will help to keep your patient at ease and allow your assessment to be more complete.
Assessing the heart involves four steps that are performed in a specific order and are easy to confuse. The four steps are to inspect, palpate, percuss, and auscultate the heart. While learning these steps in nursing school they were easy to confuse, and years after graduating I still feel that these steps can be tricky. I have found that practicing this process on a family member or friend is very helpful and at the same time gives them a free and thorough cardiac assessment. While practicing on my Dad I found that he had high blood pressure which he was not aware of and as a result started eating healthy and incorporating exercise into his lifestyle and has brought his blood pressure down significantly. A helpful memory tip in remembering the order of the steps is to think: I'll Properly Perform Assessment which equals too: Inspection, Palpation, Percussion, and Auscultation.
Inspect: the first step which is to inspect the heart involves taking a moment to assess the patient's general appearance. It is important to note his skin color, temperature, turgor, and texture. Is the patient obese or overly thin? Next, inspect the chest area, looking for landmarks such as the sternoclavicular area and the suprasternal notch to describe your findings and to identify structures. It is important to note if the patient has any heaves, pulsations, or retractions .
Palpate: It is important when you perform this second step to use a gentle touch. This allows your patient to feel less nervous and remain relaxed and additionally helps you to not obscure any pulsations. The first important step is to palate the apical impulse. The apical impulse involves the first heart sound and at times can be hard to decipher. To make sure that you are actually feeling the apical impulse and not a muscle spasm, use one hand to palpate the patient's carotid artery and other hand to palate the apical impulse. Note the size, intensity, location, and duration of the apical impulse. In addition, note any heaves or thrills, this would feel like a fine vibration.
Percussion: this involves tapping on the surface to determine the underlying structure. Sometimes the percussion step is not performed and isn't as useful as the other assessment techniques, but it is helpful in locating cardiac borders. Cardiac percussion is normally performed at the anterior axillary line and progresses toward the sternum at the third, fourth, and fifth intercostals spaces. The sounds of the heart changes from resonance to dullness over the left border of the heart, which usually occurs at the midclavicular line.
Auscultation: this is a very important step and allows you to learn a great deal about the heart. This step usually involves a lot of practice; therefore try to be easy on yourself as you first start out. Cardiac auscultation also involves a lot of patience as you decipher between what heart sounds you are hearing. When you start out begin by warming your stethoscope in your hands, your patient will appreciate this immensely. You use the bell of the stethescope to hear low-pitched sounds and the diaphragm to hear high-pitched sounds. An important step is to auscultate your patient in three different positions: sitting up, lying on his left side, and lying on his back with the head of the bed raised to a 30 to 45 degree angle. Trying these different positions is crucial if you are having a difficult time hearing the patient's heart sounds. When the patient is seated and leaning forward or lying on his left side it brings the heart closer to the surface of the chest which makes it easier to hear. While you are listening identify the normal heart sounds which are S1 and S2. In addition, listen for any adventitious sounds which would be the third and fourth heart sounds which are murmurs and rubs. Some important tips while auscultating include: avoid listening through clothing or wound dressing, concentrate carefully as you listen for each sound, and ask your patient to breathe normally and to hold his breath at times to enhance sounds that may be difficult to hear. Additionally, until you gain proficiency with auscultation(which can take awhile) explain to your patient that you may be listening to his chest for a long period of time and that it does not necessarily mean anything is wrong.
The cardiac system is very detailed and fascinating. These steps are just a small part of the whole cardiovascular system. Bringing out your nursing school books are great ways to refresh your memory on heart locations and different ways to assess the heart. Practice is the best way to feel confident and professional as you are performing a cardiac assessment on your patient. I hope you find these steps helpful and are able to use and incorporate them into your patient's assessment. Practice makes perfect!