When evaluating a client for possible disorders of the cardiovascular system, the nurse must attend to individual and population risk factors, cultural influence, and socioeconomic factors that may impact preventative and curative health. Client health history, physical examination findings, and diagnostic test results will also play an important role in cardiovascular system assessment.

Risk Factors, Cultural, and Socioeconomic Influences on Cardiovascular System Health

Risk Factors

Cardiovascular disease (CVD) remains a significant global health concern, requiring providers to conduct a comprehensive risk assessment to guide client prevention and management strategies. A thorough client history is foundational for evaluating CVD risk, encompassing both modifiable and nonmodifiable risk factors. Understanding contributing risk factors provides essential insights into understanding an individual’s susceptibility to developing CVD and helps health care professionals tailor interventions effectively.

In the context of client history, identifying modifiable risk factors is crucial. Modifiable risk factors are risk factors that an individual can control through their actions, behavior, or lifestyle choices. These include factors such as tobacco use, physical activity, dietary habits, stress management, and sleep habits. Metabolic syndrome is a group of conditions that increases a person’s risk of coronary heart disease, diabetes, and stroke. The conditions include elevated blood pressure, blood glucose, and triglyceride levels, as well as increased waist circumference.^[1] Understanding an individual’s modifiable risk factors allows health care providers to provide specific educational interventions to help prevent cardiovascular disease.^[2]

Nutritional history, in particular, plays a pivotal role in cardiovascular health. See Figure 5.16^[3] for an image illustrating healthy food choices. When first assessing cardiovascular risk, it can be helpful for individuals to provide a 24-hour food intake log. Providers may ask for individuals to record this for a brief period of time, often one to three days to help understand dietary patterns. Understanding an individual’s food and fluid intake over a brief period provides insight on dietary patterns and identifies deficiencies or excesses. It can be especially helpful to examine an individual’s saturated and trans fat intake, as well as cholesterol, salt, and dietary sugar.^[4],[5]

Assessing nonmodifiable risk factors is also important. Nonmodifiable risk factors are those that cannot be changed. Age, gender, and ethnic origin all contribute to an individual’s CVD risk profile. Gathering information about chronic diseases, family history, and medication history helps in gauging potential risk. Family history and genetics play a crucial role in assessing overall risk. A positive family history of coronary artery disease (CAD) in a first-degree relative emerges as a major risk factor, often outweighing other factors such as hypertension, obesity, diabetes, or even sudden cardiac death. Understanding the age, health status, and cause of death of immediate family members helps in gauging the genetic predisposition to CVD.

Social history, including occupation and lifestyle, also provides context for identifying environmental risk factors. By systematically addressing these factors, health care professionals can form a comprehensive risk assessment foundation.^[6]

Cultural Factors

Recognizing the role of cultural beliefs and practices in cardiovascular health is integral to a holistic risk assessment. Dietary preferences and lifestyle habits by individuals based on their cultural beliefs may impact their CVD risk. Figure 5.17^[7] emphasizes the potential impact of cultural beliefs and practices on dietary preferences. Considering these cultural aspects helps nurses tailor interventions that are culturally responsive and more likely to be effective with diverse clients.^[8],[9]

Involving family members and/or significant others responsible for cooking and shopping is invaluable when providing dietary teaching. By engaging them in discussions about healthy food choices and meal preparation, the nurse ensures that interventions align with cultural values and family dynamics, fostering positive, long-term health outcomes.

Socioeconomic Factors

Socioeconomic factors significantly influence cardiovascular risk, contributing to health disparities observed across different populations. Understanding the impact of an individual’s economic status is essential, as financial limitations can impact their access to healthy foods and health care resources.^[10]

Additional socioeconomic factors like income, education, and access to health care can also amplify or mitigate CVD risk. Individuals from disadvantaged backgrounds may face challenges in adopting healthy lifestyles due to limited resources or stressful environments. Access to healthy foods, such as fruits and vegetables, may pose a challenge in areas with limited grocery stores or markets. Additionally, nutritious foods are often more expensive and may create a financial burden for individuals with limited income. These factors contribute to health inequalities and highlight the importance of addressing socioeconomic determinants of cardiovascular health.^[11]

See the following box for a case scenario illustrating risk factor identification.

Assessment

A comprehensive assessment is essential because cardiovascular disease can impact the functioning of all body systems if the transportation of blood, nutrients, oxygen, and waste products to and from various organs and tissues is affected. A comprehensive assessment includes health history, physical examination, laboratory studies, and diagnostic testing. This section will discuss the generalities of a comprehensive assessment related to the cardiovascular system. Additional details related to specific diseases are described in each cardiovascular condition section in the remainder of the chapter.

Health History

A detailed medical and family history may reveal an underlying cardiovascular disorder. Document personal or family history of cardiovascular disease such as heart attack, heart arrhythmias, valvular disorders, stroke, high blood pressure, high cholesterol, or diabetes. Heart disease in first-degree relatives such as parents, siblings, or children can indicate genetic risk for CVD and other cardiac conditions.

Personal risk factors should also be assessed, including the following^[12]:

• Past or current tobacco use, including the type and amount consumed and the length of exposure
• Caffeine intake
• Alcohol use, including the number of drinks per week
• Drug use

Physical Assessment

Conducting a thorough examination of all body systems provides the nurse with cues regarding potential cardiovascular disorders. Early identification of abnormal findings and notification of the health care provider can lead to prompt intervention and management and improve client outcomes. Table 5.3a summarizes assessments for each body system for abnormal findings that can be related to cardiovascular disease.

Table 5.3a. Abnormal Findings by Body System Related to CVD^{[13],[14],[15],[16],[17],[18]}

Focused Cardiovascular System Assessment

A focused cardiovascular assessment involves assessment of the precordium (area over the heart) to identify signs of potential abnormalities, as well as peripheral assessments.

Precordium Assessment

Assessment of the precordium involves inspection, palpation, and auscultation of heart tones.^[19]

Inspection

• Chest Configuration: View the chest configuration for any abnormalities, such as pectus excavatum (depression of the chest) or pectus carinatum (protrusion of the chest).
• Pulsations: Observe any abnormal pulsations or heaves (visible or palpable movements of the chest wall) in the precordial area, which could be indicative of cardiac hypertrophy.

Palpation

• Apical Impulse: Palpate for the point of maximal impulse (PMI), which is the location where the apex of the heart touches the chest wall. It is usually found in the fifth intercostal space at or just medial to the midclavicular line. Note the size, location, and amplitude of the PMI.
• Thrills: Use the palm of your hand to palpate for thrills (vibratory sensations) over the precordium, particularly in areas where murmurs are suspected.

Auscultation

• Follow a systematic pattern when auscultating heart sounds. See Figure 5.18^[20] for an illustration of thoracic landmarks for auscultation. The traditional order is as follows:
  • Aortic area: Second right intercostal space
  • Pulmonic area: Second left intercostal space
  • Erb’s point: Third left intercostal space
  • Tricuspid area: Fourth left intercostal space at the lower left sternal border
  • Mitral area (also referred to as “apical”): Fifth left intercostal space at the midclavicular line
• In each of these areas, listen for the normal heart sounds (S1 and S2). S1 is the first heart sound, often described as “lub,” and corresponds to the closure of the atrioventricular valves (mitral and tricuspid valves). S2 is the second heart sound, described as “dub,” and corresponds to the closure of the semilunar valves (aortic and pulmonic valves). S2 may occur during inspiration, which is considered a normal variation.
• Listen for additional heart sounds, such as S3, S4 murmurs, and pericardial friction rub:
  • S3 (also known as a ventricular gallop) is a low frequency heart sound heard shortly after the second heart sound and preceding the normal first heart sound.
  • S4 (also known as an atrial gallop) is heard late in the cardiac cycle, just before the first heart sound.
  • Murmurs are whooshing or swishing sounds made by rapid, choppy (turbulent) blood flow through the heart that may indicate valvular heart abnormalities. Note the timing, intensity, and location of any murmurs.
  • Pericardial friction rub is a high-pitched, scratchy sound that occurs when the inflamed pericardial layers rub against each other. It is typically heard in clients with pericarditis.

Peripheral Assessment

Edema

Edema occurs as a result of a buildup of fluid within the tissues. If edema is present on inspection, palpate the area to determine if the edema is pitting or nonpitting. Press on the skin to assess for indentation, ideally over a bony structure, such as the tibia. If no indentation occurs, it is referred to as nonpitting edema. If indentation occurs, it is referred to as pitting edema.

Note the depth of the indention and how long it takes for the skin to rebound back to its original position. The indentation and time required to rebound to the original position are graded on a scale from 1 to 4. Edema rated at 1+ indicates a barely detectable depression with immediate rebound, and 4+ indicates a deep depression with a time lapse of over 20 seconds required to rebound. See Figure 5.19^[21] for an illustration of grading edema. Additionally, it is helpful to note edema may be difficult to observe in larger clients. It is also important to monitor for sudden changes in weight, which is considered a probable sign of fluid volume overload.

Capillary Refill

The capillary refill test is performed on the nail beds to monitor perfusion, the amount of blood flow to tissue. Pressure is applied to a fingernail or toenail until it pales, indicating that the blood has been forced from the tissue under the nail. This paleness is called blanching. Once the tissue has blanched, pressure is removed. Capillary refill time is defined as the time it takes for the color to return after pressure is removed. If there is sufficient blood flow to the area, a pink color should return within two to three seconds after the pressure is removed.

Life Span Considerations

Nurses consider characteristics of the pediatric clients and older adults during assessment.^[22],[23]

Pediatric Considerations

• Many profound changes occur in a newborn’s cardiovascular anatomy and physiology over the first few days and weeks following birth. It is important to distinguish normal fetal to newborn cardiovascular change and signs of abnormality such as congenital heart defects.
• Newborns have incomplete sympathetic innervation and experience greater vulnerability to environmental and physiological influences without the ability to compensate.
• Infants have higher heart rates and lower blood pressures than adults.
• A small volume of blood loss in small children can be significant. For example, 100 mL of blood loss in an infant weighing 5 kg is 10% of their total blood volume.
• Establishing IV access in infants and children can be challenging due to their small veins and increased subcutaneous tissue.

Older Adult Considerations

• Cardiac valves (especially the mitral and aortic valves) often calcify in older adults, impacting their functionality and resulting in murmurs.
• Pacemaker cells decrease in number, increasing the risk of dysrhythmias.
• Increased fibrous tissue and fat in the SA node can impact the conduction of electrical impulses to the atria.
• Increased conduction time occurs (i.e., the amount of time for an electrical impulse to travel through the SA node, atria, the AV node, the bundle of His, the Purkinje fibers, and ventricles).
• The left ventricle increases in size, impacting the quantity of blood and strength of the contractions.
• Decreased sensitivity of baroreceptors and arteriosclerosis can cause orthostatic hypotension.
• Limited fluid intake (due to prescribed fluid restrictions, an attempt to manage incontinence, or decreased mobility in obtaining and drinking fluids) creates viscous blood and increases the risk for developing thrombi.
• Varicosities may develop due to the loss of elasticity of the veins, weaker leg muscles, and muscle atrophy from less exercise.

Laboratory and Diagnostic Testing

Laboratory and diagnostic testing are ordered by health care providers to identify and diagnose cardiovascular conditions.

Laboratory Studies

Several key laboratory values that play a vital role in cardiovascular assessment include troponins, CK (creatine kinase), myoglobin, lipids (total cholesterol, triglycerides, HDL, and LDL), CRP (C-reactive protein), B-type natriuretic peptide, electrolytes, coagulation studies, and thyroid studies. Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.”

• Troponins: Troponins are myocardial muscle proteins released into the bloodstream with injury to myocardial muscle. Elevated troponin levels indicate cardiac necrosis or an acute myocardial infarction (MI). Troponin T and I are highly specific to cardiac tissue, making them essential markers for diagnosing cardiac events.^[24]
• CK (creatine kinase) and CK-MB: CK is an enzyme specific to cells of the brain, myocardium, and skeletal muscle. CK-MB is primarily found in myocardial muscle. CK-MB levels show a predictable rise and fall during three days, with a peak level occurring around 24 hours after the onset of chest pain. Monitoring CK and CK-MB aids in the diagnosis and assessment of MI.^[25]
• Myoglobin: Myoglobin is a low-molecular-weight heme protein found in cardiac and skeletal muscle. It is the earliest marker detected after an MI, appearing as early as two hours after the event and declining rapidly after seven hours. However, myoglobin is not cardiac specific, making it less reliable than troponins for MI diagnosis.^[26]
• B-type natriuretic peptide (BNP): BNP is a protein that is released by the heart, primarily in response to increased pressure or stress on the heart muscle. This protein plays a crucial role in regulating blood volume and blood pressure. Elevated levels of BNP in the blood can be indicative of heart failure.^[27]
• Lipids: Lipid panel laboratory tests include the examination of high-density lipoproteins (HDL), low-density lipoproteins (LDL), and triglycerides. Total cholesterol is a combined measurement of the HDL and LDL numbers. Lipid profile assessments are crucial for identifying cardiovascular risk factors. Elevated total cholesterol, triglycerides, and LDL levels are associated with atherosclerosis and an increased risk of coronary artery disease (CAD). Conversely, higher levels of HDL are considered protective against CAD.^[28]
• CRP (C-reactive protein): CRP is the most studied marker of inflammation. Elevated CRP levels can result from any inflammatory process in the body. While not specific to cardiovascular assessment, measuring CRP is valuable for assessing cardiovascular risk, especially in middle-aged or older individuals. Higher CRP levels may indicate an increased risk of cardiovascular events.^[29]
• Electrolytes: Many electrolyte imbalances can affect the heart’s electrical activity and muscle function^[30]:
  • Sodium (Na+): Sodium is the most common electrolyte in extracellular fluid and plays a crucial role in regulating blood pressure, maintaining fluid balance, and transmitting nerve impulses. Elevated sodium levels can cause high blood pressure and edema.
  • Potassium (K+): Potassium is the most common electrolyte inside cells and is essential for normal muscle and nerve function, including heart rhythm. Abnormal potassium levels can result in arrhythmias and muscle weakness and can be caused by kidney disease and certain medications.
  • Calcium (Ca2+): Calcium is essential for muscle contraction, blood clotting, and bone health. It is tightly regulated by hormones such as the parathyroid hormone and calcitonin. Abnormal calcium levels can affect muscle and nerve function and bone health.
  • Magnesium (Mg2+): Magnesium is involved in numerous biochemical processes, including muscle and nerve function, energy metabolism, and bone health. Abnormal magnesium levels can lead to muscle cramps, irregular heart rhythms, and other issues.

• Coagulation studies: Coagulation studies assess the blood’s ability to clot and include prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT). Abnormal results can indicate a risk of clot formation or bleeding.
  • Prothrombin time (PT): PT measures the time it takes for blood to clot after a substance called thromboplastin is added to a blood sample. It primarily evaluates the extrinsic and common coagulation pathways. PT is often used to monitor the effect of anticoagulant medications like warfarin and to diagnose bleeding disorders.
  • International normalized ratio (INR): INR is a standardized measurement derived from the PT. It is used to ensure consistency in PT results between different laboratories. INR is particularly important for individuals on anticoagulant therapy (e.g., warfarin) to monitor and maintain their blood’s clotting ability within a target range.
  • Activated partial thromboplastin time (aPTT): aPTT measures the time it takes for blood to clot after a substance that activates the intrinsic and common coagulation pathways is added to a blood sample. It is used to assess factors involved in the clotting cascade, including factors VIII, IX, XI, and XII. aPTT is used to diagnose and monitor conditions like hemophilia and to evaluate the effects of anticoagulant medications such as heparin.
  • Thrombin time (TT): TT measures the time it takes for fibrinogen to convert into fibrin. It primarily assesses the final step of the clotting process. TT may be used to evaluate specific clotting disorders and fibrinogen abnormalities.
  • D-dimer: D-dimer is a marker for the presence of blood clots, specifically the breakdown products of fibrin that result from the dissolution of a blood clot. Elevated levels of D-dimer may suggest the presence of an active blood clotting process in the body. D-dimer tests are often used in the diagnosis of conditions like deep vein thrombosis (DVT), pulmonary embolism (PE), and disseminated intravascular coagulation (DIC).^[31]

• Thyroid function tests: Thyroid hormones help regulate heart rate and cardiac output. Hypothyroidism can lead to bradycardia (slower heart rate), increased cholesterol levels, and increased risk of atherosclerosis, which can contribute to cardiovascular disease. Conversely, hyperthyroidism can cause tachycardia (rapid heart rate) and increased cardiac output, potentially leading to conditions like atrial fibrillation or heart failure. Thyroid hormones also play an important role in regulating the sensitivity of the heart to adrenaline (epinephrine) and norepinephrine, which are hormones that influence heart rate and contractility. Abnormal levels of T4 and T3 can disrupt these processes and affect heart function.^[32]

Diagnostic Testing

Providers who suspect a cardiac disorder may initially order a chest X-ray to assess the size of cardiac structures and to check for fluid in the lungs. Other common diagnostic tests related to the cardiovascular system include electrocardiograms (ECG), Holter monitors, echocardiograms, cardiac stress tests, and cardiac catheterization.

Electrocardiogram

An electrocardiogram (EKG or ECG) is an important diagnostic tool to help identify cardiac abnormalities. See Figure 5.20^[33] for an image of a client undergoing an ECG and Figure 5.21^[34] for an image of a normal ECG strip showing normal sinus rhythm. ECG records the electrical activity of the heart and allows health care professionals to assess the heart’s rhythm and identify various cardiac conduction abnormalities called dysrhythmias or arrhythmias. Cardiac dysrhythmias can range from asymptomatic conditions to life-threatening events that impair the delivery of oxygenated blood to tissues and organs. See Table 5.3b for a summary of common dysrhythmias. An ECG is also a critical tool for diagnosing myocardial ischemia (i.e., a “heart attack”). Specific changes in an ECG tracing can reflect elevation or depression of the ST segment, allowing a provider to identify where potential ischemia or infarction of cardiac tissue may be occurring within the heart.^[35]

Table 5.3b. Common Cardiac Arrhythmias

Holter Monitors

Holter monitors are portable devices that continuously record a client’s heart rhythm and electrical activity over an extended period, typically 24 to 48 hours. See Figure 5.22^[37] for an illustration of a Holter monitor. Its primary purpose is to detect and document irregularities in the heart’s electrical patterns, such as arrhythmias, which may not be captured during brief in-office ECGs. Additionally, clients may activate a trigger on a Holter device to denote the occurrence of cardiac symptoms, such as increased shortness of breath, fatigue, or dizziness. A cardiologist can then review the symptom timestamp and accompanying EGC tracing to identify if an arrhythmia occurred at that time.^[38]

By providing a thorough real-time analysis of a client’s heart rate and rhythm during their daily activities, the results of a Holter monitor help health care professionals identify and diagnose a variety of cardiac conditions, including atrial fibrillation, ventricular tachycardias, bradycardias, and heart blocks.

Echocardiogram

A transthoracic echocardiogram is a noninvasive diagnostic test that uses sound waves (ultrasound) to create real-time images of the heart’s structure and function. See Figure 5.23^[39] for an image of a pediatric client undergoing a transthoracic echocardiogram. A trained sonographer or cardiologist applies a gel and a transducer to the client’s chest. The transducer is moved to different areas of the chest to obtain various views of the heart, including the heart chambers, valves, walls, and blood flow patterns. Doppler ultrasound is also commonly used during echocardiography to determine the speed and direction of blood flow through the valves and chambers of the heart.

A transesophageal echocardiogram (TEE) is similar to transthoracic although it is invasive in nature. The provider may order a transesophageal echocardiogram to gain a more detailed view of the heart and aorta. To perform a transesophageal echocardiogram, a probe and ultrasound wand are guided down the esophagus and close to the position of the heart, and the ultrasound is performed. Conscious sedation is administered to enhance client comfort. Both diagnostic tools are very helpful for identifying heart failure, valvular regurgitation, and stenosis.^[40],[41]

A key measurement during an echocardiogram is the client’s ejection fraction. Ejection fraction measures the amount of blood the left ventricle of the heart pumps out to the body with each heartbeat. For example, an ejection fraction of 60 percent means that 60 percent of the total amount of blood in the left ventricle is pushed out with each heartbeat. A normal heart’s ejection fraction is between 55 and 70 percent. The ejection fraction is used to diagnose and monitor heart failure.

Cardiac Stress Test

A cardiac stress test (also known as an exercise stress test or treadmill test) is a diagnostic procedure used to evaluate the performance and function of the heart during physical activity. It helps identify potential heart problems, such as coronary artery disease (CAD), arrhythmias, and heart valve issues. During a cardiac stress test procedure, a client is asked to walk on a treadmill or pedal a stationary bicycle with the exercise requirement gradually increasing over time. See Figure 5.24^[42] for an image of a cardiac stress test.

During the procedure, client symptoms are monitored for occurrence of chest pain, shortness of breath, fatigue, and dizziness. The client’s ECG is also closely monitored to detect any changes in heart’s electrical activity during exercise. The test is terminated when the client has achieved a target heart rate, if symptoms of discomfort occur, if the client’s experiences significant ECG changes, or if the maximum duration of exercise has occurred. Cardiac stress tests may also be performed with the administration of medications such as dobutamine or adenosine for individuals who are unable to tolerate exercise-induced stress testing. The medications can simulate the workload that would typically occur during physical exercise.^[43] 

Cardiac Catheterization

Cardiac catheterization is a valuable diagnostic procedure in the evaluation and management of cardiovascular health alterations. Cardiac catheterization, performed in association with a coronary angiogram, is a diagnostic procedure used to visualize the coronary arteries, heart chambers, and great vessels. It involves the insertion of a thin, flexible tube (catheter) into the blood vessels, usually through the femoral or radial artery, to access the heart and its surrounding structures.^[44],[45] See Figure 5.25^[46] for an image of a cardiac catheterization procedure with the image of the client’s coronary arteries and heart chambers displayed on the monitor.

Providers order cardiac catheterization for many diagnostic purposes, such as the following:

• Assessment of Coronary Artery Disease (CAD): Identifies blocked or narrowed coronary arteries, guiding decisions about interventions such as angioplasty (use of a balloon to stretch open a blocked artery) or stent (insertion of a small mesh tube to help expand an artery) placement.
• Evaluation of Valvular Heart Disease: Measures pressure gradients across heart valves and assesses valve function.
• Investigation of Congenital Heart Abnormalities: Assesses structural abnormalities of the heart and great vessels in pediatric and adult clients.
• Measurement of Cardiac Function: Directly measures cardiac output, ejection fraction, and other important parameters of cardiac function.

See the following box regarding nursing interventions to prepare a client for cardiac catheterization.

During cardiac catheterization, a catheter is inserted through the access site and advanced through the blood vessels until it reaches the coronary arteries or the heart chambers. Contrast dye is injected through the catheter, and X-ray imaging is used to visualize the coronary arteries and identify areas of narrowing or blockage. Measurements of pressures and blood oxygen saturations within the heart may be taken to identify abnormalities in valve function. If areas of blockage or narrowing are noted within the coronary arteries, an angioplasty may be performed where a balloon is inflated to help open the coronary artery. After the balloon is inflated, a stent is often inserted to help keep the coronary artery open. After the procedure has been completed, the catheter is removed, and pressure is applied to the access site until bleeding stops.^[48] Clients will receive instruction to minimize movement and pressure to the catheter insertion site for a specified period. The site should be closely monitored for recurrent bleeding and pressure should be immediately applied to the insertion site if bleeding recurs. Urinary output is also closely monitored to ensure the contrast dye has not impeded renal function. Additional post-procedure education should include assessing for infection, reporting any signs of chest discomfort, knowing the guidelines for activity progression, etc.

See the following box for a case study related to a cardiac catheterization procedure.