Cardiovascular Assessment: Heart Sounds, Pulses, and Perfusion

Cardiovascular assessment evaluates the function of the heart and blood vessels through heart sounds, pulses, blood pressure, and perfusion indicators. A solid baseline assessment helps nurses detect decreased cardiac output, perfusion problems, and peripheral vascular disease early.

Components of Cardiovascular Assessment

• Heart sounds — valve closure and blood flow (e.g., S1 and S2 present)
• Pulses — peripheral circulation (e.g., radial pulses equal bilaterally)
• Blood pressure — cardiac output and resistance (e.g., 120/80 mmHg)
• Skin — perfusion status (warm, pink, dry)
• Capillary refill — peripheral perfusion (<2 seconds)
• Jugular veins — central venous pressure (no distension)

Heart Sounds

• S1 ("lub") — closure of the mitral and tricuspid valves; marks the beginning of systole; best heard at the apex.
• S2 ("dub") — closure of the aortic and pulmonic valves; marks the end of systole; best heard at the base.
• S2 split during inspiration is a normal physiological finding.
• S3 — early diastole; may indicate heart failure in older adults, but can be normal in younger patients.
• S4 — late diastole; suggests decreased ventricular compliance, often seen with hypertension.
• A thrill is a palpable vibration over the chest wall and indicates a grade 4 or higher murmur.
• A bruit is a blowing sound over an artery, suggesting turbulent flow from narrowing.

Heart Sound Locations

• Aortic — Right 2nd intercostal space (aortic valve)
• Pulmonic — Left 2nd intercostal space (pulmonic valve)
• Erb's point — Left 3rd intercostal space (S2 splitting)
• Tricuspid — Left 4th intercostal space (tricuspid valve)
• Mitral (apex) — Left 5th intercostal space, midclavicular line (mitral valve)

Murmur Grading (1–6)

• Grade 1 — very faint, difficult to hear
• Grade 2 — soft but clearly audible
• Grade 3 — moderately loud, no thrill
• Grade 4 — loud, with a palpable thrill
• Grade 5 — very loud; heard with partial stethoscope contact
• Grade 6 — extremely loud; heard without stethoscope touching the chest

Heart Sound Assessment Technique

• Position patient supine or semi-Fowler's with the head of bed at ~30°.
• Place the stethoscope directly on the skin.
• Use the diaphragm for high-pitched sounds (S1, S2, most murmurs).
• Use the bell for low-pitched sounds (S3, S4).
• Auscultate in a systematic pattern across all valve areas.
• Identify S1 by palpating the carotid pulse — S1 occurs with the pulse.
• Have the patient breathe slowly or hold their breath briefly if needed.

Peripheral Pulses

Pulse Locations

• Carotid — neck; central perfusion
• Brachial — upper arm; blood pressure
• Radial — wrist; routine assessment
• Femoral — groin; lower body perfusion
• Popliteal — behind the knee; peripheral circulation
• Dorsalis pedis — top of foot; peripheral perfusion
• Posterior tibial — medial ankle; peripheral perfusion

Apical Pulse and Pulse Deficit

• The apical pulse is used when the radial pulse is irregular or hard to palpate and provides the most accurate heart rate.
• A pulse deficit occurs when the apical pulse exceeds the radial pulse and requires two clinicians to assess simultaneously.
• A pulse deficit is commonly associated with atrial fibrillation (an irregularly irregular rhythm).

Pulse Amplitude (0–3)

• 0 — absent, not palpable
• 1+ — weak, diminished
• 2+ — normal/expected
• 3+ — bounding, increased

Pulses should always be compared bilaterally; asymmetry suggests arterial obstruction.

Pulse Assessment Technique

• Use the pads of the index and middle fingers — never the thumb.
• Apply light pressure first, then increase gradually.
• Assess rate, rhythm, and amplitude.
• Note rhythm as regular, regularly irregular, or irregularly irregular.
• Palpate carotid arteries one side at a time only.
• Flex the knee slightly when assessing the popliteal pulse.
• Use a Doppler if a pulse cannot be palpated.

Edema Assessment

Edema is fluid accumulation in the interstitial space, commonly seen in heart failure and peripheral vascular disease.

• Inspect for swelling and palpate over bony areas for pitting.
• Note indentation depth and rebound time; document location.

Pitting Edema Grading

• 1+ — mild; slight indentation, rapid return
• 2+ — moderate; deeper indentation, returns in 10–15 seconds
• 3+ — deep; noticeable swelling, returns in >1 minute
• 4+ — very deep; gross swelling, takes 2–5 minutes to resolve

Other Cardiovascular Components

• Measure blood pressure in both arms initially; a difference >10–15 mmHg may indicate vascular disease.
• Orthostatic hypotension — drop of 20 mmHg systolic or 10 mmHg diastolic with position change.
• Capillary refill should be <2 seconds.
• Jugular venous distension (JVD) — assess at 45°; a height >3–4 cm indicates increased central venous pressure.
• Skin assessment includes color, temperature, and moisture; cool or pale skin suggests poor perfusion.

Common Exam Traps

• Do not use your thumb to palpate pulses.
• Do not palpate both carotid arteries at the same time.
• Do not document an absent pulse without Doppler confirmation.
• Do not confuse S3 (early diastole) with S4 (late diastole).
• Do not ignore a pulse deficit.

Key takeaways

• S1 marks the start of systole, S2 the end; S3 and S4 suggest abnormal ventricular function in adults.
• Murmurs are graded 1–6; a thrill indicates grade 4 or higher.
• Peripheral pulses are graded 0–3, with 2+ normal; always compare bilaterally.
• A pulse deficit (apical > radial) is classic for atrial fibrillation and requires two-nurse assessment.
• Capillary refill <2 seconds is normal; JVD signals elevated central venous pressure.
• Use the diaphragm for high-pitched sounds and the bell for low-pitched S3/S4.