1. Cardiac Assessment:
More Than Just Heart Sounds
Telemetry
Course
Natalie Bermudez, RN, BSN, MS
Clinical Educator for Cardiac Telemetry

2. Importance of Assessment
• RNs are the 24/7 surveillance system
for the patient (Linda Aiken)
• RNs are rescue workers (Suzanne
Gordon)
• RNs are the integrators of all things
(Maggie McClure)
• RNs are the coordinators of care

3. Essentials of Assessment
• Empathic listening
• Ability to interview patients of different
ages, moods, and backgrounds
• Techniques for examining different
body systems
• Clinical Reasoning (I.e. critical
thinking)
– Putting it all together!

4. Key Points of Assessment
• Listen to the patient, they will often
help in leading to a diagnosis
• Focus on the patient, not the task; be
observant
• Be a detective; dig for clues
• Don’t take anything for GRANTED!
– Always check things out, especially “gut
feelings”

5. Key Points of Assessment
• Be proactive; anticipate your patients
needs
– Act before your patients gets into trouble
• When possible, round with the
physician
– Discuss any abnormal findings, especially
when you’re not sure of their significance

6. History
• Drives the physical assessment as well
as the diagnostic studies and treatment
• Lays the groundwork for the nurse-
patient relationship
• Provides key information
• Should not be bypassed

7. History of Present Illness
• Why is the patient seeking care?
• Have patient describe in his/her own words
Presenting Symptoms:
• Ask patient to describe symptoms
• Use a systematic approach to evaluating
symptoms
– OLDCARTS
– NOPQRST

8. OLDCARTS
• O = Onset
• L = Location
• D = Duration
• C = Character
• A = Aggravating/Alleviating factors
• R = Radiation
• T = Timing
• S = Site

9. NOPQRST
• N = Normal
• O = Onset
• P = Precipitating, Provoking, Palliative
• Q = Quality or Quantity
• R = Radiation or Region
• S = Severity or other Symptoms
• T = Time and Treatment

10. Cardiovascular Complaints
Chest Pain or Pressure
• Most common symptom in CV presentation
• Utilize the NOPQRST method of assessment
• N = Normal
• O = Onset
• P = Precipitation, Provoking, Palliation
• Q = Quality and Quantity
• R = Radiation and Region
• S = Severity and other Symptoms
• T = Time and Treatment

11. Chest Pain or Pressure
Onset
• Start suddenly or gradually – most angina starts at
low intensity and builds
• Time of day that discomfort started - some MI’s
occur in the morning after the patient rises and
begins activity
• When did the discomfort 1st begin – today or a few
days ago???
• MI may occur with activity or after a heavy meal
• Periods of increased myocardial demand

12. Chest Pain or Pressure
Precipitation, Provoking, Palliation
• Chest pain caused by CAD is often precipitated by
exertion
• Other precipitants are exposure to cold or heavy meals
• Associated factors – does the discomfort change
with inspiration or position change?
• What relieves the discomfort? –
• NTG, how many; if no relief, ask about storage of NTG
• Does the discomfort change with activity change,
such as rest?

13. Chest Pain or Pressure
Quality and Quantity
• Angina or ischemic discomfort is often described as
heaviness, pressure, tightness, or squeezing
• Stabbing, intermittent, knife-like descriptions are
not likely to be due to cardiac ischemia
• Remember – Ask the patient to describe the
discomfort

14. Chest Pain or Pressure
Radiation and Region
• Substernal region in the most common location for
discomfort with cardiac origin
• Anginal or ischemic discomfort is likely to radiate to
the jaw, either arm, or back
• However, discomfort is not always substernal even if
it is of cardiac origin
• Region of discomfort is usually larger than a fingertip
and often the size of a hand or closed fist

15. Chest Pain or Pressure
Severity and Other Symptoms
• Severity is subjective
• Ischemic pain can range from mild to severe
• Rate on a scale of 0 – 10
• Assess for other symptoms – nausea, vomiting,
dyspnea, diaphoresis, etc.

16. Chest Pain or Pressure
Time and Treatment
• Length of time since onset of symptoms
• How long do the symptoms last?
• Treated in the past for the same symptoms?

17. Dyspnea
• Can be due to pulmonary or cardiac problems
• Symptoms occur with activity or rest?
• If with activity, what level?
• Decreased activity tolerance demonstrated by DOE
might be anginal
• Onset gradual or sudden?
• Orthopnea - Difficulty breathing when flat
• PND – dyspnea that occurs 1-2 hours into sleep,
relieved by sitting
• How many pillows does the patient use?

18. Cough and Hemoptysis
• Heart Failure or Pulmonary Embolus
• Signs of Left-Sided HF
• Wet or dry cough
• Frequency – chronic or new onset
• Occurs only with activity?
• Sputum (amount, color, and consistency)
• Hemoptysis – blood-streaked, frothy pink, frank
• May be present with mitral valve stenosis, pulmonary embolus,
pulmonary hypertension, or tuberculosis

19. Palpitations
• Awareness of heartbeat
• May occur with fast or normal heart rate
• May be regular or irregular
• May occur with aortic or mitral regurgitation,
pregnancy
• Tachydysrhythmias may result in palpitations
• A-Fib or A-Flutter with RVR, SVT, VT

20. Syncope
• Distinguish between dizziness, fainting and
syncope
• Room spinning or whirling indicates a
vestibular disorder
• Fading off or blacking out is usually caused by
insufficient blood supply to the brain
• Hypotension or marked bradycardia or tachycardia
• Usually occurs when systolic BP < 70 mmHg
• Suspect orthostatic hypotension if occurs with position
changes
• Vasovagal stimulation

21. Physical Assessment
• Find a systematic approach that works for you
• Always begin your shift with a thorough
physical assessment (baseline)
• Always complete assessment with respect for
patient’s privacy
• Room should be quiet
• Perform assessment from patients right side

22. Physical Assessment
• Find a systematic approach that works for you
• Always begin your shift with a thorough
physical assessment (baseline)
• Always complete assessment with respect for
patient’s privacy
• Room should be quiet
• Perform assessment from patients right side

23. Vital Signs
Blood Pressure
Hypotensive or Hypertensive
Heart Rate
Bradycardia or Tachycardia
Respiratory Rate
Bradypneic or Tachypneic
O2 Saturation
Hypoxia/Hypoxemia

24. Blood Pressure
Blood pressure is a measurement of the
force exerted by blood as it pulsates
through the arteries (Kozier et al, 2002),
SBP = CO x SVR

25. Blood Pressure
Systolic blood pressure (SBP) is the
pressure of the blood as a result of
contraction of the ventricles
Diastolic blood pressure (DBP) is the
pressure when the ventricles are at rest
DBP is the lower pressure that is present at
all times within the arteries
(Kozier et al, 2002, p. 33)

26. Blood Pressure
Blood pressure is affected by factors such as
CO [preload, contractility, afterload]; distension
of the arteries; and the volume, velocity, and
viscosity of the blood (Smeltzer et al, 2008, p. 799)
Blood pressure is an indicator of adequate or
inadequate perfusion
Inadequate perfusion may be a result of high or
low blood pressures

27. Blood Pressure
Hypotension: SBP < 90 and/or DBP < 60
Hypertension: SBP > 140 and/or DBP > 90

28. Blood Pressure
• Technique for measuring blood pressure
is important
– Sitting up
– Arm at the level of the heart with support
– Place cuff over brachial artery
– Use appropriate cuff size
• Too small – falsely elevated BP
• Too big – falsely decreased BP

29. Orthostatic Blood Pressure
• Technique for measuring orthostatic BP
– Use the same arm
– Wait at least 5 minutes between measurements
– Lying, sitting, standing
• Orthostatic Hypotension if:
– Fall of SBP > 20 mmHg
– Fall of DBP > 10 mmHg

30. Mean Arterial Pressure
Mean Arterial Pressure (MAP)
Range = 70 – 110 mmHg
The average pressure of the arteries
MAP = (2 x DBP) + SBP
3
MAP is multiplied by 2 because diastolic phase
lasts longer than the systolic phase
If B/P 120/75, then MAP = ______

31. Mean Arterial Pressure
MAP is the average arterial pressure during a
cardiac cycle
MAP is considered to be the perfusion
pressure seen by organs in the body
MAP that is > 60 mmHg is enough to sustain
the organs of the average person
If MAP is < 60 mmHg, then the organs are not
being adequately perfused and they will
become ischemic

32. Noninvasive BP
Measurement
Two Common Noninvasive Indirect
Methods of B/P Measurement
Ausculatory & Palpatory

33. Ausculatory BP Measurement
External pressure is applied to a superficial
artery (most commonly the brachial).
The stethoscope, or a Doppler device,is
placed over the artery and the pressure is
assessed by listening for the 5 phases of
sounds
a.k.a. Korotkoff’s sounds

34. Korotkoff’s Sounds

35. Palpatory BP Measurement
Used when Korotkoff’s sounds cannot be
heard and electronic equipment to
amplify the sound (i.e. doppler) is not
available
The pulses are palpated, instead of
auscultated
The first palpation is the SBP
DBP is not able to be assessed

36. Invasive BP Measurement
Common Invasive Methods of B/P
Measurement:
• Arterial B/P Monitoring
• Pulmonary Artery Pressure Monitoring
• Cardiac Output Monitoring
• Cardiac Catheterization
• Central Venous Pressure Monitoring
(Donofrio et al, 2005)
Cardiac Telemetry Patients are not monitored
invasively!!!!

37. Factors Affecting BP:
• Age: Increased r/t arterial wall rigidity
• Sex: Male BP > Female B/P
• Exercise: Increases B/P
• Medications: Some Increase, some decrease
• Stress: Increases B/P
• Race: African American males –
increased after age 35

38. Factors Affecting BP:
• Obesity: Predisposed to hypertension
• Diurnal Variations: lowest in AM, peaks
in late afternoon/early evening
• Fever/Heat/Cold: Increased with fever
(increased metabolic rate), decreased
w/ external heat (vasodilation), and
increased with cold (vasoconstriction)

39. Heart Rate
Pulse is the term used to describe rate,
rhythm, and volume of the heartbeat
A pulse is produced by ventricular
contraction which creates a wave of
blood through the arteries
The pulse reflects the heartbeat
(Kozier et al, 2002, p. 23)

40. Characteristics of a Pulse
Pulse should be characterized as:
• Thready, weak, strong, or bounding
• Equal bilaterally or not
• Rhythm regular or irregular

41. Heart Rate & Blood
Pressure
Blood pressure is directly affected by the
heart rate
Heart rate is directly affected by blood
pressure
What does this mean…?

42. Heart Rate & Blood
Pressure
• HR is Within Defined Parameters if 60–
100
– Bradycardia if HR < 60
– Tachycardia if HR > 100
• Blood pressure affects HR and HR affects
BP
– If HR > 100, then BP decreases
– If HR < 60, then BP decreases
– If BP decreases then HR increases

43. Factors Affecting Heart Rate:
Age: increased age, decreased HR
• Sex: Male HR < Female HR
• Exercise
• Fever: Increased heart rate (peripheral
vasodilation r/t elevated temp)
• Medications
• Hypovolemia/Dehydration: Increased heart
rates
• Stress
• Position: Higher when standing

44. Respiratory Rate
Respiratory rate is calculated by counting
the number of inspirations/respirations
per minute
Normal range is 15 – 20 bpm
Depth & Rhythm (pattern)
(Kozier et al, 2002)

45. Breathing Rates
Eupnea – normal RR that is quiet, rhythmic, and
effortless
Tachypnea – rapid respirations, marked by
shallow breaths (> 20 per minute)
Bradypnea – abnormally slow breathing
(< 8 per minute)
Apnea – cessation of breathing
(Kozier et al, 2002, p. 31)

46. Breathing Rates
Cheyne-Stoke – Fast, deep respirations of 30 –
170 seconds punctuated by periods of apnea
lasting 20 – 60 seconds
Kussmaul’s – fast (over 20 per minute), deep
(resembling sighs), labored respirations without
a pause
(Goldberg et al, 1997, p. 764)

47. Factors Affecting RR
• Age: rate & depth decrease with age
• Exercise: Increased rate & depth
• Fever: Increased
• Medications: Narcotics cause respiratory
depression
• Stress: Increased rate & depth
• Homeostasis (acidosis/alkalosis): Increased
or decreased rate
(Kozier et al, 2002)

48. Oxygen Saturation
Normal = 95% - 100%
Below 70% is life threatening
Pulse oximeter - measures arterial blood
oxygen saturation
Can detect hypoxemia before clinical signs
& symptoms are apparent
(Kozier et al, 2002)

49. Pulse Oximeter
2-Part Sensor
2. Two light-emitting diodes (LEDs) – one
red and one infrared
Transmit light through nails, tissue, venous blood, &
arterial blood
2. Photodetector (opposite side of LEDs)
Measures the amount of red and infrared light absorbed
by oxygenated & deoxygenated hemoglobin in arterial
blood and reports it as SaO2.
(Kozier et al, 2002)

50. Factors Affecting 02 Sat:
• Hemoglobin: regardless of low Hemoglobin
levels, if the hemoglobin is fully saturated
the SaO2 will still be “normal”
• Circulation: Will be inaccurate if the area
under the sensor has impaired circulation
• Activity: Shivering or excessive movement
of the sensor site may interfere with
accurate readings
(Kozier et al, 2002, p. 39)

52. Inspection
Lips/Tongue
Blue-tinged?
Dry/Cracked?
Consider:
Cyanosis – lack of circulation
Dehydration

53. Inspection
Skin:
Hair
Cyanosis/Pale? Distribution?
Redness? Turgor?
Consider:
Cardiac or Vascular insufficiency
Dehydration

54. Assessment of Cardiac Perfusion and
Pulmonary Congestion
WARM and DRY WARM and WET
No Congestion Congestion
Normal Perfusion Normal Perfusion
COLD and DRY COLD and WET
No Congestion Congestion
Low Perfusion Low Perfusion

55. Inspection
Neck:
Jugular Vein Distension?
Consider:
Right-sided heart failure
Hypervolemia
Cardiac Tamponade
Constrictive Pericarditis

56. Inspection/Palpation
Nails:
Clubbing?
Color?
Thickness?
Capillary Refill?
Consider:
Cardiac or Vascular insufficiency
Chronic cardiac or pulmonary disease

57. Capillary Refill
If greater than 3 seconds may indicate:
•Dehydration
•Shock
•PVD
•Hypothermia

58. Inspection
Abdomen:
Ascites?
Pulsating
Mass?
Consider:
Right-sided heart failure
Abdominal Aortic Aneurysm

59. Inspection
Lower Extremities:
Cyanosis/Pale?
Redness?
Hair Distribution?
Turgor?
Edema?
Consider:
Cardiac or Vascular insufficiency
Left-sided Heart Failure

60. Inspection/Palpation
Legs/Ankles/Feet:
Edema?
Pulses?
Sensation? Consider:
Pain? DVT
Heart Failure
Peripheral Vascular Disease

61. Palpation
Upper Extremities:
Pulses?
Sensation?
Consider:
Peripheral Vascular Disease
DVT

62. Edema 4-Point Scale
Grade Description Depth of Indentation
0 None N/A
1+ Trace Up to ¼-inch
2+ Mild ¼- to ½-inch
3+ Moderate ½- to 1-inch
4+ Severe Greater than 1-inch

63. Pulse Points
•Carotid Evaluation for:
•Radial •Presence
•Brachial •Laterality
•Femoral •Strength
•Popliteal
•Posterior Tibial
•Dorsalis Pedis

64. Pulse 4-Point Scale
Grade Description
0 Absent
1+ Palpable, but thready and
weak; easily obliterated
2+ Normal, easily identified; not
easily obliterated
3+ Increased pulse; moderate
pressure for obliteration
4+ Full, bounding; cannot
obliterate

65. Terminology of Pulse
Variations
•Pulsus Magnus – strong and bounding
•Pulsus Parvus – thready
•Pulsus Alternans – large amplitude followed by low
amplitude (with a regular rhythm)
•Pulsus Bisferiens – double-peaked systolic impulse
(cardiomyopathy)
•Water-Hammer pulse – rapid rising and collapsing
(aortic regurgitation)

67. General Points
When assessing heart sounds:
•Need a quiet room
•Stand to the right of the patient
•Having patient roll slightly to the left accentuates S3, S4
and mitral murmurs, especially mitral stenosis
•Having patient lean forward accentuates aortic
regurgitation
•Right-sided heart sounds are better heard on inspiration
•Left-sided heart sounds are better heard during
expiration

69. Heart Sounds

70. First Heart Sounds
S1 = Lub
•Closure of the mitral and tricuspid valves
•Beginning of ventricular systole and atrial
diastole
•Palpate the carotid pulse to assist with ID
•Occurs just before carotid pulse
•Best heard in mitral area

71. Second Heart Sounds
S2 = Dub
•Closure of the aortic and pulmonic valves
•End of ventricular systole
•Beginning of ventricular diastole
•Best heard at pulmonic area and Erb’s
point

72. Third Heart Sounds
S3 = Lub DubDa
•Ventricular gallop
•Caused by increased atrial or ventriuclar filling
•May be normal in children and pregnancy
•Best heard in left lateral decub position
•Associated with R or L ventricular failure,
ischemia, aortic regurg, mitral regurg, or systolic
dysfunction

73. Fourth Heart Sounds
S4 = DaLub Dub
•Atrial gallop
•Occurs during late ventricular diastole
•Caused by atrial contraction and propulsion of
blood into a noncompliant, stiff ventricle
•Best heard in left lateral decub position
•Associated with restrictive cardiomyopathy,
ischemia, and aortic stenosis

74. Murmurs

75. Systolic Murmurs
a)Midsystolic
• Innocent murmurs (normal heart)
• Physiologic murmurs (pregnancy,
fever, anemia)
• Aortic stenosis, HCM, pulmonic
stenosis
b) Pansystolic
• Regurgitation (mitral or tricuspid)
• Ventricular Septal Defect
c) Late Systolic
• Mitral valve prolapse

76. Diastolic Murmurs
a)Early diastolic
• Aortic regurgitation
b) Middiastolic
• Aka presystolic
• Mitral stenosis
c) Late diastolic
• Tricuspid stenosis
• Mitral stenosis
• Left-to-right shunts

77. Continuous Murmurs

78. Grading Murmurs
Gradation of Description
Murmurs
Very faint, heard only after listener has "tuned in"; may not be heard
Grade 1 in all positions
Quiet, but heard immediately after placing the stethoscope on the
Grade 2 chest
Moderately loud
Grade 3
Murmur is very loud, with palpable thrill
Grade 4
Murmur is extremely loud, with palpable thrill, and can be heard if
Grade 5 only the edge of the stethoscope is in contact with the skin, but
cannot be heard if the stethoscope is removed from the skin
Murmur is exceptionally loud, with palpable thrill, and can be heard
Grade 6 with the stethoscope just removed from contact with the chest.

79. Respiratory Assessment
•Auscultate anteriorly and posteriorly
•Patient should be sitting up!

80. Normal Breath Sounds
Bronchial (upper)
•Expiratory longer than inspiratory
•Loud and higher in pitch
Bronchovesicular (middle)
•Equal inspiratory and expiratory
Vesicular (lower)
•Soft or low pitched
•Heard through inspiration and 1/3 expiration

81. Adventitious Sounds
Crackles (Rales)
•Discontinuous
•Intermittent, non-musical, brief
•Like dots in time
•Crackles that do not clear with cough indicate
abnormal lung tissue such as fluid (pulmonary
edema)
•If clears with cough, atelectasis or secretions

82. Adventitious Sounds
Wheezes
•Continuous
•Musical
•High-pitched with hissing or shrill quality
•Narrowing of airways

83. Adventitious Sounds
Rhonchi
•Continuous
•Relatively low-pitched
•Snoring quality
•Suggest secretions in large airways

85. Abdominal Assessment
Auscultation:
•Normal sounds – clicks & gurgles
•Occur at 5- to 15-second intervals
•Absent = no sounds detected within 2 minutes
•Hypoactive = less than normal
•Hyperactive = more than normal
•Listen for bruits

86. Abdominal Assessment
Palpation:
•Soft, firm, or rigid
•No masses or tenderness
•Rebound pain (may suggest peritoneal
inflammation or peritonitis)
Inspection:
•Concave, flat, protuberant, distended???

87. Genitourinary Assessment
•Intake and output
•Indicates both renal and cardiac function
•Foley catheter
•Check for orders and insertion date

88. References
Bickley, L. S. (2007). Bates’ pocket guide to physical examination and history
taking, (5th ed.). Philadelphia, PA: Lippincott, Wilkins, and Williams.
Davis, L. (2004). Cardiovascular nursing secrets: Your cardiovascular
questions answered by exoerts you trust. St. Louis, MO: Elsevier Mosby.
Donofrio, J., Haworth, K., Schaeffer, L., & Thompson, G. (Eds.). (2005).
Cardiovascular care made incredibly easy. Ambler, PA: Lippincott, Williams,
and Wilkins.
Goldberg, K., Johnson, P., & Lear-Olimpi, M. (1997). Handbook of clinical skills.
Springhouse, PA: Springhouse Corporation.
Kozier, B., Erb, G., Berman, A., & Snyder, S. (2002). Kozier’s and erb’s
techniques in clinical nursing: Basic to intermediate skills, (5th ed.). Upper
Saddle, NJ: Prentice Hall.
Moser, D. K., & Riegel, B. (2008). Cardiac nursing: A companion to braunwald’s
heart disease. St. Louis, MO: Saunders Elsevier.
Smeltzer et al. (2008). Brunner and suddarth’s textbook of medical-surgical
nursing, (11th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.