Ideally the patient should be positioned between 30° and 45° and the patient's chest should be exposed to enable a comprehensive assessment. Note that due to the condition of the patient, the patient may be uncomfortable or in pain; in such cases, the assessment should be adjusted to meet the needs of the patient. It can be helpful to visualize the structure of the heart as you undertake inspection.

Part of cardiovascular inspection is measuring the jugular venous pressure (JVP) (Figure 2.14). JVP reflects the pressure in the right atrium and is a good indicator of cardiac function (Powell [64]). To measure JVP, locating the right internal jugular vein is paramount. The vein runs deep within the sternomastoid muscle so it is not directly visible (Bickley and Szilagyi [9]). Instead, it can be located by looking for its pulsation within the sternomastoid muscle (Bickley and Szilagyi [9]) (Figure 2.14).

The palpable pulse in an artery reflects the pressure wave generated by the ejection of blood into the circulation from the left ventricle. When taking a pulse assess:

The rate and rhythm of the pulse are usually determined at the arterial artery; use the larger pulses (brachial, carotid or femoral) to assess pulse volume and character (Mills et al. [50]).

A weak pulse can be a sign of various conditions, including decreased cardiac output (Rushforth [74]). A bounding pulse can indicate an increased cardiac output, which can be present in hypertension and anaemia (Rushforth [74]). Pulses on each side of the body should be compared simultaneously if possible. There are two exceptions to this: the popliteal pulse and the carotid pulses. The nurse will need to use both hands to assess each popliteal pulse; the carotid pulses should always be palpated separately, as doing both together may make the patient feel faint.

The nurse should feel across the chest for evidence of pain, heaves, thrills and lifts. Lifts and heaves are forceful cardiac contractions that can result in transient movement of the sternum and/or ribs and if present will be felt through the flat of the hand being lifted rhythmically during palpation (Bickley and Szilagyi [9]). They can be a sign of an enlarged ventricle or atrium or sometimes a ventricular aneurysm (Bickley and Szilagyi [9]). Thrills are vibrations that can be felt from light palpation over the chest, usually over the areas of the heart valves, and are the result of a loud heart murmur. They will be felt most clearly using the ball of the hand palpating in the area of the murmur and may feel like a buzzing or vibration (Bickley and Szilagyi [9]).

The nurse should palpate the apical impulse (point of maximum impulse). Start from the fifth intercostal space, inside the mid‐clavicular line (Camm and Camm [13]). If the impulse is difficult to find, the patient should be asked to roll slightly onto their left side. Observe the apical impulse for size, amplitude, location, impulse and duration.

When auscultating, the heart sounds should be characterized and identified, as should any added sounds and/or murmurs (Mills et al. [50]). All elements of the cardiac cycle can be heard on auscultation and thus it is important to identify all of them (Camm and Camm [13]). The sound of the beating heart is often described as ‘lub dub’ and is caused by the closure of valves (Powell [64]). The ‘lub’, which is also referred to as ‘S1’, is the sound made when the mitral and tricuspid valves are closing; it is often heard best over the apex. The ‘dub’ or ‘S2’ is the sound made when the aortic and pulmonary valves close (Camm and Camm [13]; Powell [64]) and can be heard well across the precordium. There are extra sounds that can sometimes be heard called ‘S3’ and ‘S4’. S3 is occasionally heard immediately after S2 and is caused by the vibration of rapid ventricular filling (Mills et al. [50]). S4 can rarely be heard immediately before S1 and marks atrial contraction. Both of these sounds can indicate a change in ventricular compliance (Bickley and Szilagyi [9]).

Murmurs can be heard in a number of different conditions; they are caused by turbulent blood flow. While murmurs are sometimes harmless, they can indicate valvular heart disease (Bickley and Szilagyi [9]). Heart sounds and murmurs that originate in the four valves radiate widely; see Figure 2.16 for an illustration of the relevant auscultation points.

Assessment of carotid bruits is an important component of cardiovascular assessment. Bruits are often described as ‘whooshing’ sounds and can indicate atherosclerotic arterial disease (Bickley and Szilagyi [9]).

The patient's health history and the nurse's knowledge of anatomy and physiology will help to guide when it is appropriate to do a cardiovascular physical examination. The list of presentations that may lead to a cardiovascular examination is vast; some examples include: