13.11: Assessment of the Cardiovascular System III: Palpation

Palpation involves feeling the body to evaluate texture, size, consistency, and tenderness for assessing cardiovascular health. The following steps are organized in a head-to-toe order:

Jugular Venous Pressure (JVP) Measurement

Position the patient at a thirty- to forty-five-degree angle or in a semi-fowler's position. Look for the highest point of pulsation in the internal jugular vein and measure the vertical distance to the angle of Loius or sternal angle. A normal JVP is 3-4 cm above the sternal angle, corresponding to 6-8 cm H₂O relative to the right atrium. Elevated JVP can indicate right-sided heart failure or fluid overload.

Thorax Examination

Key Areas for Heart size and vibration:

1. Aortic Area: Second intercostal space (ICS) right of the sternum.
2. Pulmonic Area: Second intercostal space left of the sternum.
3. Tricuspid Area: Fifth intercostal space left of the midsternal line.
4. Mitral Area: Fifth intercostal space, left midclavicular line.

Point of Maximal Impulse (PMI):

It is located at the fifth intercostal space, on the left midclavicular line. A displaced PMI may indicate cardiac enlargement.

Heaves and Lifts:

Palpate for heaves or lifts along the left sternal border. These are forceful chest wall movements that may indicate ventricular hypertrophy or other cardiac abnormalities.

Pulse Assessment

Carotid, Radial, and Femoral Arteries: Assess the pulse for rate, rhythm, and force.

1. Bradycardia (<60 beats/min): Rest, sleep, athletic conditioning, Sinoatrial/Atrioventricular node damage, β-blockers, hypothyroidism.
2. Tachycardia (>100 beats/min): Exercise, anxiety, hypovolemia, shock, increased cardiac output, hyperthyroidism.
3. Absent Pulse: Local atherosclerosis, trauma, embolus.
4. Bounding Pulse: Hyperkinetic states, anxiety, fever, anemia, hyperthyroidism.

Capillary Refill

Capillary refill assesses peripheral perfusion and cardiac output. Position the patient's hands near heart level, squeeze a nail bed until it blanches, then release and observe the time it takes for color to return. Normal refill time is less than 2 seconds. Delayed refill can indicate poor perfusion, shock, or peripheral vascular disease.

Extremities Examination

Temperature, Moisture, and Edema:

1. Press the skin for pitting edema; lasting depression indicates venous return issues. Grade pitting edema from 1+ to 4+ based on severity.

Asymmetry in Limb Circumference:

1. Check for measurable swelling, which may indicate venous thromboembolism, varicose veins, or lymphedema.

Cold Extremities:

1. Hands and/or feet that are cold to the touch may suggest peripheral arterial disease, reduced cardiac output, or severe anemia.