Tips for Cardiac Nurse Assessment

Are you a nursing student or nurse getting started on a cardiac unit and want to learn how to perform an outstanding cardiac patient assessment? Maybe in school they went over an incredibly detailed assessment that didn’t seem like something you could do quickly or easily at the bedside. Physicians and their extenders also do a few things that are not necessary for a bedside cardiac nurse assessment.

The level of detail that the bedside nurse will use to perform this skill is unique, so let’s go over it together.

Tips for Cardiac Nurse Assessment

Step 1: Chart Review

Before I assess my cardiac patient, it’s helpful to get some background. Many times, cardiac patients have multiple crucial pieces of information in their chart. But there’s quite a few places to check. Let’s go over a few.

Medical History

Reviewing their history can really help inform an in-person assessment. This history might be located on the front of the chart, or you can open their latest History and Physical note made by a physician. For example, if they have a history of atrial fibrillation and heart failure, I would expect to see a-fib on their telemetry as well as medications like metoprolol, furosemide, potassium, and even anticoagulation in their med list.

Things to look for:

• Cardiac surgery – MVR, AVR, CABG are just a few
• Heart failure
• Cardiac devices – pacemaker, defibrillator, filters, LVADs
• Lung conditions – COPD, emphysema, lung cancer, pneumothorax, hemothorax
• Vascular issues – blood clots, pulmonary embolisms, grafts
• Cardiac procedures – caths, stent placement, transesophageal echocardiogram, cardioversion
• Renal and electrolyte issues – these can impact the heart’s electrical conduction and blood volume

I would just do a quick scan and ensure I had penitent history (not every since piece of history) written on my report sheet.

Medication Review

Next, I’d open up their Medication Administration Record (MAR) and look to see what meds they’re getting. I would start with ACTIVE cardiac meds. I’ll look for any antihypertensives, anticoagulants, anti-dysrhythmics, statins, and more.

Next, open up the COMPLETED tab and see if they had any meds within the last 24 hours that were either 1-time doses or stopped. This will let you if they needed a dose of potassium for a low K+ level, or if they just completed an Amiodarone drip series, etc. Really helpful information can been seen in this tab.

Then, peek at the PRN tab. These are the as needed meds given recently. See if they needed a dose of an antihypertensive overnight, a bolus because their blood pressure was too low.

Vital Sign Review

Now, take a quick look at their vitals over the last day or so. Are any wildly out of range? Are any RED? Are they all there? I will only write down specific vitals out of range, that needed to be treated, and possibly the range. For example, if their heart rate appears to range between 70-90, I’ll write on my report sheet “HR 70-90”.

Lab Review

(Are you still with me? Sorry, this is a lot. Hang in there.)

Pop open their recent results and see what we’ve got. Electrolytes are really important for cardiac patients because imbalances can cause impairment in the electrical conduction of their heart. I tend to scan for values that are out of range and write down those.

Consider looking at electrolytes (Mag and Potassium are arguably the most important in cardiac patients), blood counts (H/H), white count, and bonus if they recently had an echocardiogram and an ejection fraction (EF) is listed.

Again, I just click through to take a look at these and don’t usually write them down unless it’s far out of range or actionable.

Telemetry Review

Last but certainly not least is to see what their heart is doing on the monitor. This information won’t be in their physical chart, but it will be on a monitor at the nurse’s station. I like to glance at this before I go into the room so I know what I’m working with. This allows me to gleam important information. So, if I see pacing spikes on the monitor, will anticipate that during their assessment to see a pacing pack under their skin on the left chest.

If I see a really slow heart rate, I’ll make sure I ask them about any dizziness or lightheadedness, especially when getting out of bed.

Note of Encouragement – For YOU!

That was a lot, but keep in mind, it’s a quick chart review. Imagine this is like clicking a few tabs on your smartphone before walking into the room. This is the same amount of energy as checking your Instagram DMs, the comments on your last TikTok, and scrolling through to see the latest emails in your inbox. The more you do it, the faster it will be, and the easier it will be for you to pick out the important information.

I also tend to do this at the beginning of my shift to get baseline foundation in my brain and don’t look at all of that every single time prior to going into the room.

Step 2: Physical Assessment

Next, it’s time to actually assess your patient.

If this is your main shift assessment, it’s important to have a set of vitals around the same time so you can correlate your assessment findings.

Observations

• At rest, do they seem short of breath? How hard are they breathing?
• What does their skin look like? Is it consistent with their ethnicity? Do they seem pale, ashen, blue, etc? Is it dry? Are they sweating?
• When you walk into the room, do they notice you? Can they turn their head, acknowledge you, and converse with you?
• Do they independently use and move all 4 extremities with ease, or is there a deficit?
• If you’re in an ICU and they’re on a monitor and asleep, note what their vitals are BEFORE you wake them, and again during your assessment to see if there is a large difference.

Head to Toe

I first ask basic orientation questions: “Please tell me your name, where you are, what year it is, and why you’re here with me.”

While they’re talking, I observe their face for equal movement and notice how they speak (if it’s clear, garbled, and so forth.) I also pay attention to how hard they’re working to breathe while speaking and if they can manage their secretions (are they choking on their spit?).

I have them smile to check facial symmetry. I have them look at me, hold their head steady and cover one eye, and then ask them to look directly at my nose. Then I hold up fingers in all four quadrants, one at a time, and see if they can tell me the correct number. Then, I do the other eye. This assesses visual quadrants and if they have a field cut.

Then, I see if they can follow my fingers with just their eyes. I hold their head steady by gently placing my index finger on their chin, then use my other hand to make a big X and see if they can follow it fully and equally with both eyes. I’m watching for nystagmus, and this exercise assesses their extraocular movements.

I’ll grab a penlight and shine a light in each eye (make sure you warn them first). I am looking at the pupil’s shape, size, and responsiveness to light.

Then I grab my stethoscope to listen to their lungs, heart, and bowels. I personally find it flows better to listen to posterior lung sounds (on their back) first. I will ask them to lean forward and listen to 8 spots on the back. (This is a great example of where, scroll down to BACK.) While listening, I’m visualizing their back. If they are bed bound, you can roll them to the side, but may need help. This would also be a great time to assess the coccyx of any bed bound patient if you do need to get them on their side to listen!

I then gently set them back on the bed and listen to lung sounds on the front. If they’re on an oxygen device, I’m observing what kind it is and noting if it’s hooked up correctly and working appropriately.

Then, I tell them to breathe normally so I can hear their heart.

Here is where I listen to their heart:

• The Aortic Valve – located at the second intercostal space right sternal border.
• The Pulmonary valve – located at the second intercostal space left sternal border.
• Erb’s Point – located at the third intercostal space left sternal border.
• The Tricuspid Valve – located at the fourth intercostal space at the left sternal border.
• The Mitral Valve – located at the fifth intercostal space midclavicular line

I listen for that good ol’ lub-dub, as well as for any odd sounds like a pericardial friction rub, murmurs, or additional heart sounds.

Finally, I move down to the abdomen and listen to each quadrant of their intestines to note the bowel sounds. Then, I casually flip my stethoscope back onto my neck and feel like such a badass every time I do. After, I gently palpate the abdomen to see if their is any distention or discomfort.

Then, I palpate radial pulses. After, I put my fingers in their hands and ask them to gently squeeze, then push and pull. At this time, I’m noting any skin issues and looking for any edema on the extremities. I’m also looking around at any IV insertion sites and the status of their dressings, as well as any devices that are inserted (chest tubes, arterial lines, central lines, dialysis catheters, feeding tubes, tracheostomies,

Finally, let’s work down to the feet. I feel pedal pulses (dorsalis pedis and posterior tib). If I can’t palpate them, I definitely get a portable doppler to do so. This is really important in cardiac patients! There is often edema in the feet, so I check that as well.

I ask about sensation and if they have any numbness or tingling anywhere. Many cardiac patients will say “Well, I always have that!” In response, I typically ask, “Is the numbness and tingling you’re feeling now different than your normal?”

For a motor assessment, I’ll then ask them to pick one leg up and hold it up for a few seconds, then the other one. I cap it off by having them push down on my hands (“Like you’re stepping on the gas pedal!”) and pull back up against my hands to check for dorsiflexion and extension strength and if it’s equal.

Step 3: INTERROGATION (Just Kidding: Questions I Like to Ask)

• How’s your pain? If they have pain, I ask more (where is it, what’s it feel like, does anything make it worse or better)
• How’s breathing? Do you feel short of breath, or like it’s a lot of work to get air in and out?
• How’s going to the bathroom? Are you able to have a bowel movement normally? Is there any pain or discomfort while urinating?
• How’s sleep? Did you get any last night?
• What am I missing? Is there anything you wanted to let me know about how you’re feeling?

Step 4: Stuff in the Room

If a patient is on any device, this is now the time to look at it to ensure it’s working correctly, at the right rate, etc. Examples of different “stuff” you should check out:

• IV pumps
• PCA pumps
• Any oxygen delivery device
• Arterial line
• Ventilator
• Bair hugger
• Any urinary catheter
• Fecal management device
• Telemetry monitor
• Continuous pulse oximetry monitor
• Sequential compression devices
• … and more!

At the beginning of your shift, please make sure it’s working correctly. I’ve started shifts where I noticed the alarm on the bedside monitor was OFF entirely, the IV pump was programmed incorrectly, and the oxygen wasn’t hooked up to the wall.

Step 5: Educate

Before I leave, I let the patient know the plan for the day. I tell them things like the doctor will be by at some point, we’ve got certain labs or tests to expect, that I’ll be back with meds at a certain time, and all of that jazz. Cardiac patients tend to have a lot of diagnostics, labs, and changes so I like to stay on top of that which cuts down on questions and confusion.

If it’s mid-shift, I let them know I’ll be back in a few hours unless they hit that call bell earlier. I let them know someone else might beat me to it, but I’m still here for the rest of the shift if they need me specifically.

Getting ready to have patients on telemetry, but need a little refresher first?

Telemetry Basics Brush-Up from FreshRN is a self-paced mini-course where we walk through the basics of cardiac electrical conductivity and how that is reflected on your telemetry strips, discuss rhythms based on the level of urgency you should have, go over insider tips and tricks, and more.

Conclusion

I know that sounded like SO MUCH, but I promise it becomes very second nature the more that you do it. As you get into the groove of it, you’ll get more efficient. Before you know it, you’ll be assessing like a pro!

More Resources for Cardiac Nurse Assessments:

• Telemetry Basics Brush-Up – mini course
• 5-Lead EKG Interpretation: Tips for Nurses – blog post
• Cardiac Nursing For Beginners – blog post
• Cardiac Assessment – What Nurses Need To Know – blog post
• Cardiac Nurse – A Typical Day – blog post