What part of the stethoscope should the nurse use when assessing the carotid arteries of an older client with cardiovascular disease?

Cardiovascular disease is the leading cause of death in the UK. According to the British Heart Foundation (BHF, 2021), coronary heart disease (CHD) accounts for 64 000 deaths each year or one death every 8 minutes. Many risk factors increase the likelihood of developing cardiovascular disease. Those from a South Asian, African or Afro Caribbean background are at a higher risk of developing heart and circulatory diseases than White Europeans. Additionally, high blood pressure, smoking, diabetes, high cholesterol, poor diet and lack of exercise are risk factors (BHF, 2021). A cardiovascular examination should be an essential consideration of a complete assessment and examination by an advanced practitioner (AP).

Ideally, a focused cardiovascular assessment is warranted after a thorough evaluation has identified a potential cardiac problem. However, there are occasions when this may differ, for example if a patient developed signs and symptoms that changed from their baseline assessment. The primary benefit of this focused assessment is that it helps guide the AP along their line of questioning regarding the patient's signs and symptoms and move swiftly to complete a more detailed physical cardiovascular examination. The assessment and clinical examination findings will guide the diagnosis, differential diagnosis, further tests needed, and treatment options available. Throughout this process, the patient's privacy and concerns should be paramount, utilising advanced communication skills.

Receiving the history

A good history taking alone accounts for 75% of diagnoses before performing a physical examination and ordering additional tests are needed (Lown, 1999). With regards to the heart, this will provide information about the patients' current complaints/symptoms, personal and family history, lifestyle and health practices. A thorough cardiovascular history will not only provide information about the potential or actual state of the heart disease but will guide the practitioner through the focused clinical examination. In addition to collecting subjective data around cardiovascular status, it is vital to identify opportunities for health education (Webber and Kelley, 2014).

History of present health

It is crucial to ask questions about the patients' present health history or complaints. The mnemonic SOCRATES is very useful in assessing complaints of chest pain.

• S: site – where is the pain
• O: onset – when did it start?
• C: character – describe your chest pain (stabbing, crushing, squeezing etc)
• R: radiation – does the pain radiate anywhere?
• A: associated symptoms – do you have any other symptoms with this (sweating, nausea, feeling cold and clammy etc)
• T: timing – clarify how the symptoms have changed over time
• E: exacerbating factors – what makes the pain worse or better?
• S: severity – rate the pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible?

When exploring the patient's complaints of chest pain, the advanced practitioner must bear in mind that chest discomfort or pain has many origins, and they must hone their skills in the differentiation of these. For example, the pain of myocardial ischemia or infarction may be reported as a squeezing, strangling, burning, or crushing chest pain. In contrast, the patient with an aortic dissection will say that the chest pain is tearing in nature. Pleuritic chest pain may be described as sharp, stabbing, and intense when taking a deep breath in and relived by sitting up (Walker et al, 1990; Hinkly et al, 2021). This type of chest pain may indicate pericarditis and pulmonary embolism.

Table 1. Common presentations and differential diagnosis

Suneja et al, 2020

Additionally, you may also consider asking questions around tachycardia and palpitations:

• Does your heart ever skip a beat or beat faster than usual?
• What makes this better or worse?

According to Webber and Kelley (2014), tachycardia indicates a weakened heart muscle and an attempt by the heart to increase cardiac output (CO). In contrast, palpitations occur when there is a problem with the heart's conduction system or during the heart's attempt to increase CO by increasing the heart rate. On the other hand, palpitations do not always indicate heart disease (Bickley and Szilagyi, 2009).

Other symptoms to explore include:

• Do you feel fatigued easily?
• Please described when the fatigue started; was it gradual or sudden?
• Do you notice this more at any specific time of the day?

Patients with reduced cardiac output often complain of tiredness or fatigue. Cardiovascular-related fatigue occurs more in the evening or as the day progresses (Webber and Kelley, 2014). However, some medications and medical conditions like beta-blockers and anaemia can cause patients to report a feeling of tiredness and fatigue.

Shortness of breath or difficulty breathing is a common problem and may represent dyspnoea, orthopnoea or paroxysmal nocturnal dyspnoea (PND) (Bickley and Szilagyi, 2009). Shortness of breath related to a cardiac origin must be distinguished from that of a respiratory source. Therefore, consider asking the following questions:

• Do you have difficulty breathing or shortness of breath?
• When does this occur and what activities make it worse or better?
• How many pillows do you use to sleep?
• Does the difficulty in breathing wake you up at night?

Dyspnoea may result from heart failure or pulmonary disorders. It can result from left ventricular failure or obstructive lung disease (Adam and Osborne, 2009). Orthopnoea indicates the need to sit more upright to breathe easily due to the accumulation of fluids in the lungs when lying flat. Here, the patient may tell how many pillows they need to sleep on or whether they need to sit upright. PND describes episodes when the patient suddenly awakens due to dyspnoea and orthopnoea, usually 1–2 hours after retiring to bed. This episode prompts the patient to sit more upright in bed or stand up (Bickley and Szilagyi, 2009).

Past medical history

The past medical history is essential because it helps to obtain information regarding health-related risk factors, previous history of heart defects, murmurs, heart surgery or cardiac balloon interventions, bleeding disorders, and the use of any heart medications. Any history of heart disease may warrant questioning as to whether they ever had an electrocardiogram (ECG) or echocardiogram done and the results, any stress test done or serum cholesterol (Kaplow and Hardin, 2007). These questions are essential because any history of congenital disease will indicate an inability of the heart to pump effectively. Previous heart surgeries may change the heart sounds, and hyperlipidaemia suggests a risk factor for coronary artery disease. A history of having an ECG will assist in the evaluation for changes in the cardiac conduction or any previous cardiac insult or injury such as a myocardial infarction (MI).

Family history, lifestyles and health practices

The family history is essential because it allows the identification of patients at high risk for cardiovascular disease. Questions to ask include:

• Is there any history of hypertension, MI, coronary heart disease, elevated cholesterol levels or diabetes in your family?

Lifestyle questions to explore when conducting a cardiovascular assessment include:

• Do you exercise regularly? If so, what type of exercise and how often do you exercise?
• How much alcohol do you consume per day/week/month? When was your last alcoholic drink?
• Do you smoke cigarettes or tobacco? How many packs per day and how many pack years?
• What type of stress do you have in your life, and how do you cope?

As an AP, it is good practice to summarise the key points back to the patient to ensure clarity. Additionally, it provides an opportunity to address any questions or concerns.

Red flags

Red flags are signs and symptoms found in the patient's history and clinical examination (Ramanayake and Basnayake, 2018). Some red flags are more general such as loss of weight or appetite. In contrast, some are more specific such as haematemesis or melena (passage of black, tarry stools), indicative of gastric intestinal bleeding. Evaluation of red flags plays an integral part in the decision-making process during history taking and clinical examination, especially where there are fewer investigatory facilities such as in primary care.

The red flags related to the cardiovascular systems are crushing chest pains, syncope, palpitations, shortness of breath, tingling/numbness in the arm, altered level of consciousness, sweating, cold clammy skin, cyanosis, and the impending feeling of doom.

Clinical examination

The primary purpose of the clinical examination is to identify any sign of heart disease and initiate early treatment or referral. Other body systems may be relevant in the cardiovascular assessment, such as the circulatory or respiratory systems, to provide a comprehensive overview or holistic picture of the situation.

It is important to consider the immediate and visual inspection to gather more data.

• Look and listen
• Think cardiac or respiratory?
• Is the patient known to have a respiratory or cardiac problem?

Immediate investigations

Vital observations of:

• HR: rate and rhythm
• Respiration: rate and effort
• Blood pressure: both arms
• Temperature: check if paracetamol had been taken
• Pulse oximetry
• ECG: baseline interpretation

Inspection and palpation of the skin, face, eyes and mouth

This visual assessment plays an integral role in cardiovascular evaluations. The areas of the evaluation include the skin, face, eyes and mouth, looking for any abnormal colour, lesions, odours, symmetry or motion, rashes, or any other abnormalities.

Start by assessing the skin for colour, warmth, and moisture. A cold, clammy skin indicates peripheral vasoconstriction. On the other hand, warm skin to the touch means vasodilation. Certain conditions may cause this, such as increased temperature, fear, anxiety, medications, and cardiogenic or hypovolaemic shock. Bluish discolouration of the skin is associated with oxygen deficiency. To differentiate between peripheral or central cyanosis, bluish discolouration in the oral mucosa signifies peripheral cyanosis (Webber and Kelley, 2014). The presence of petechia and purpura is indicative of infective endocarditis.

It is also essential to assess for arterial perfusion in the lower extremities by having the patent lie in a supine position and elevate one of their legs above the heart level for approximately 1 minute. Then ask the patient to sit up and dangle their legs at the edge of the bed and note its colour. The elevated portion will appear slightly pale when compared to the other. Both legs should return to the same colour once the veins had time to fill in approximately 10 seconds.

Note the presence of any oedema, which can result from many disease processes, including heart failure, varicose veins and venous insufficiency.

Next, inspect the eyes for any conjunctival pallor or xanthelasma (yellowish-white lumps of fatty material accumulated under the skin on the inner parts of your upper and lower eyelids), which indicates anaemia or hyperlipidaemia. Assess the face for any signs of malar flush, which may indicate mitral stenosis. Assess the mouth for any oral candidiasis, central cyanosis, dental hygiene, and high arch palate. High arch palate is associated with a disorder called Marfan syndrome. Marfan syndrome is associated with mitral/aortic valve prolapse and aortic dissection. As a result, aortic valve-sparing root replacement can be used successfully in patients with bicuspid valves or Marfan syndrome (Bojar, 2011). As an ANP, you should always think about your scope of practice and the importance of timely cardiac referral so that early treatment can be initiated to save lives.

Inspection, auscultation and palpation of neck vessel

When assessing the neck vessels, pay close attention to any abnormalities that can be seen visually. The most important vessel in the neck area to consider is the jugular venous pulse (JVP). From this assessment, you can estimate the patients' central venous pressure (CVP) and the heart's efficiency as a pump mechanism.

Place the patient in a supine position with the torso elevated at a 30–45-degree angle. Standing on the patient's right side, ask them to turn their head slightly to the left. Look for any pulsations in the suprasternal notch or just posterior to the sternomastoid muscle (Bickley and Szilagyi, 2009).

The JVP is not visible with the patient sitting upright unless there is underlying pathology. A raised JVP indicates an increased CVP due to right-sided heart failure, pulmonary hypertension, pulmonary embolism, or cardiac tamponade.

It is imperative to rule out those factors that can cause increased intrathoracic pressure, such as laughing, crying, and coughing. Be aware of a large cervical or retrosternal goiter that may cause venous obstruction (Suneja et al, 2020).

The JVP is difficult to see in children younger than 12 years old, so this may not be valuable for cardiovascular assessment in this age group (Bickley and Szilagyi, 2009).

Auscultation of the neck vessels

After inspecting, the clinician should auscultate the carotid arteries in those who are middle-aged or older or those with a suspected or known cardiovascular disease. This assessment should be conducted over bare skin, in a quiet area and the bell of the stethoscope should be used to listen to one sound at a time. The bell picks up on low-pitched sounds (Bickley and Szilagyi, 2009). Proceed by placing the stethoscope bell over the carotid artery and ask the patient to hold their breath for a moment so that the patient's breath sounds do not conceal any vascular sounds. You are listening for the presence of a bruit, which is a whooshing or blowing sound indicating a turbulent blood flow through a narrowed vessel. Typically, there is no bruit.

Palpation of the neck vessel

Palpation is a common technique used during examination. It requires the clinician to touch the patient using the pads of the fingers while applying different strength pressures. Palpation enables the assessment of the neck for temperature, tenderness, pulsations, or masses.

Palpating the carotid artery provides valuable information regarding cardiac function and is vital to detect valvular stenosis or insufficiency of the aortic valve. With the patient in the same position when auscultating, place the index and middle finger pads on the right carotid artery medial to the sternocleidomastoid muscle and note the amplitude, contour of the pulse, elasticity of the artery, and any thrills. Usually, the contour is smooth, rapid, and follows S1 almost immediately (see later in article). The amplitude correlates with the pulse pressure.

Never assess both carotids simultaneously because a decrease in blood flow to the brain may occur and cause the patient to collapse (syncope). Be careful with older adults because atherosclerosis may cause obstruction, and compression may easily block the circulation (Webber and Keley, 2014).

Inspection of the hands

Finally, inspect the hands for any signs of clubbing and Janeway lesions that indicate congenital cardiac disease or infective endocarditis, respectively. Please note that clubbing is also present in those with respiratory problems. Look for any nicotine stains or extensor tendon xanthoma, which indicates a risk factor for cardiovascular disease. The presence of splinter haemorrhage on the nail beds is indicative of infective endocarditis. Please ensure that there is no recent injury to the nail bed.

Assessment of pulses

The next part is palpation of the peripheral arteries by noting their contour and amplitude, including the brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses. These should feel similar bilaterally.

Inspection, auscultation and palpation of the heart

Inspection

Ensure the patient is in the supine position with the head of the bed elevated to a 30–45 degree angle, stand on the patient's right side and look for the apical impulse, only visible in 20% of normal people. The apical impulse is as a result of the left ventricle moving outward during systole.

Inspecting the chest for any abnormalities is very important. Pay particular attention to pectus excavatum (breastbone pushed inwards) and pectus carinatum (breastbone pushed outwards), because they increase or decrease the anterior/posterior diameter of the chest wall and may cause displacement of the heart from its normal position. Look for any pacemaker scars that can be found on the right or left side beneath the clavicle.

Auscultation

Before starting this technique, the clinician must notify the patient that they will listen to their heart sound in many different places, so please bear with them. It would help to landmark the areas being auscultated: the aortic valve is located in the second intercostal space right to the sternal border edge; the pulmonic valve, which is in the second intercostal space left to the sternal border edge; tricuspid which is the fourth intercostal place; and the mitral valve, which is in the fifth intercostal space, midclavicular line. Often, the Z pattern is used by starting at the base of the heart moving towards the apex (Figure 1). Close attention is payed to the ‘lub’ and the ‘dub’ sounds, which correlate with the first heart sound, S1, and the second heart sound, S2, respectively.

Heart sounds: S1

The closure of the valves produces heart sounds while the opening of the valves is silent. The S1 sound is produced by the closure of the atrioventricular valves (tricuspid and mitral valve), and the S2 is produced by the closure of the semilunar valves (aortic and pulmonic valve).

Some alterations that may occur in S1 (lub) include (Webber and Kelley, 2014):

• S1 is louder than S2 in hyperkinetic states where blood viscosity increases, such as fever, anaemia, hyperthyroidism
• S1 is diminished or softer than S2 in conditions where there is delayed conduction from the atria to the ventricle as in first-degree heart block
• S1 occurs as a split sound as in bundle branch block due to conduction delaying the cardiac impulse to one of the ventricles.

Heart sounds: S2

S2 is known as the ‘dub’ of the ‘lub, dub’. Some alterations that may occur in S2 include (Webber and Kelley, 2014):

• S2 is louder than S1 in conditions with increased pressure in the aorta due to exercise, excitement, or systemic hypertension
• A diminished S2 means that S2 is softer than S1 with decreased blood pressure due to shock, or aortic or pulmonic stenosis in which the valves are stenosed or calcified
• Normal split S2 can be heard over the second or third left intercostal space and is best heard during inspiration and disappears during expiration.

During this assessment, patients should not hold their breath because any normal or abnormal split sound may disappear.

Extra heart sounds

S3 and S4 are diastolic filling sounds or extra heart sounds resulting from rapid ventricular filling (Webber and Kelley, 2014). S3 is known as ventricular gallop and occurs in the early diastole after the S2. S3 sounds are normal during pregnancy, in children, and adults younger than 30 years, in anxiety or anaemia, and best heard at the apex with the patient lying in the left lateral position, using the bell. S3 that occurs due to pathology can be found in adults aged 40 years or over due to myocardial failure.

S4 occurs as a result of ventricular resistance (noncompliance) to atrial filling. If present, it is heard during late diastole just before the S1, is low pitched, and is best heard with the bell of the stethoscope. It is known as the atrial gallop. S4 is typically found in older adults and best heard at the apex, with the patient lying in the left lateral position.

S4 that occurs due to pathology may be caused by cardiomyopathy, hypertension, aortic stenosis or coronary artery disease.

Palpation of the heart

Palpate the apical impulse, which usually lies in the fifth intercostal space, midclavicular line. Ensure the patient is lying in a supine position with the clinician standing on the right side. Using one or two-finger pads, palpate for the apical impulse, which feels like a short, gentle tap. If difficult to palpate, ask the patient to roll over onto their left side to feel the apical impulse better because the left ventricle moves closer to the chest wall. It is often difficult to feel in obese patients or those with thicker chest walls.

Increased amplitude and duration may occur due to hyperthyroidism, left ventricular hypertrophy, emotion, exercise and anaemia. An apical impulse displaced to the left or right may occur due to volume overload of the left ventricle, aortic or mitral regurgitation, right pneumothorax, left pneumothorax, pleural adhesions and volume loss in the right lung, respectively.

The examiner's senses of touch and vibrations can palpate the heaves and thrills over the precordium. The finger pads are most sensitive to vibrations, so palpate the precordium with the palms of your hands (Suneja et al, 2020).

Heaves

Place your hands parallel to the left sternal border edge to palpate for heaves. If present, it will feel like a ‘kick’ to the palm. Parasternal heaves are associated with right ventricular hypertrophy.

Thrills

A thrill is caused by turbulent blood flow through an abnormal heart and produces vibrations audible as murmurs and palpable as thrills (Suneja et al, 2020). Thrills must be assessed across each valve (APTM). To do this, place hands horizontally across each valvular area with the flats of the fingers and the palm of the hand. If present, it will feel like a vibration (phone) or cat purr.

Investigations

Diagnosing cardiovascular disease remains a challenge in general practice, although most patients present with non-cardiac causes (Bosner et al, 2009). APs play a seminal role in reliably identifying serious cardiac problems while protecting the patient from harm, unnecessary investigations, and hospital admissions. They must be able to use their skills in diagnostic reasoning and draw on their experiences to order timely and correct studies and investigations.

Investigations to consider are dependent on the resources available to the AP. However, some common studies are (Adam and Osborne, 2009; NICE, 2020):

• 12 lead ECG: must be reviewed in conjunction with the patient's history, blood results, and data from the clinical examination. Any changes on the ECG can then be extremely valuable, particularly in ruling out a diagnosis of myocardial infarction
• Serum biochemical and haematological tests: includes cardiac enzymes, urea and electrolytes, liver function test, haemoglobin, glucose, clotting studies, cholesterol, and triglyceride levels.
• Chest X-ray will provide valuable information on the heart size, the presence of pulmonary oedema, and aortic dissection
• C-reactive protein or erythrocyte sedimentation rate (ESR) to check for evidence of infection or inflammation.

Further testing may prove essential depending on the patient's clinical presentation, such as an echocardiogram, ventilation–perfusion (VQ) scan, magnetic resonance imaging (MRI) and computerised tomography (CT) angiogram.

Please refer any patient falling outside your scope of practice to a more senior colleague or hospital as soon as possible.

Recording findings

Findings should be documented accurately; they must be legible and thorough. It forms part of the standard documentation; whereby other team members must be able to read and interpret the findings accurately.

Conclusion

Conducting a cardiovascular assessment is not difficult, but it takes practice to integrate the health history and physical examination effectively. APs must be skilled in analysing all the data obtained, synthesizing the information, deducing possible problems, and identifying appropriate investigations and treatment. A timely referral is essential in saving lives.

KEY POINTS:

• A thorough history accounts for 75% of diagnosis alone before performing a physical examination. As an advanced practitioner it is important to hone skills in this area and recognise that the patient is the most significant source of information, and they can help the clinician arrive at a diagnosis promptly
• The primary purpose of the clinical examination is to identify any signs of heart disease and initiate early treatment or referral. This action will save lives leading to a reduction in the mortality rate among these patients
• It is important to know the landmarks of the valves well and become familiar with several terms related to the landmarks of the chest. The term costal refers to the ribs, and intercostal refers to the area/space between the ribs
• Although cardiovascular assessment remains a challenge in clinical practice, the advanced practitioner plays a vital role in identifying severe cardiac problems and using their diagnostic reasoning skills to order timely, correct studies and investigations. This action will prevent unnecessary investigations and hospital admissions

CPD REFLECTIVE PRACTICE:

• Can you think of some non-heart-related causes of palpitations?
• Which heart sound is known as ventricular gallop?
• How will this article change your clinical practice?