Heart Assessment 

Nursing Knowledge

Heart Assessment 

A nursing cardiovascular assessment is a systematic process used by nurses to evaluate the heart and circulatory system’s function and health. Central to clinical practice, this assessment identifies early signs of cardiovascular diseases, ensuring timely intervention and optimal patient outcomes. It encompasses a thorough patient history, evaluation of vital signs, palpation and auscultation of specific cardiac points, and an examination of peripheral pulses and edema.
Last updated: December 4, 2023

Table of contents

What is done in a cardiovascular assessment in nursing? 

A cardiovascular assessment in nursing involves evaluating the heart and blood vessels to identify potential cardiac issues. Here’s a brief outline of the components:

  • Taking a thorough history (especially: cases in the family (or past cases in patient) of heart disease, hypertension, diabetes, high cholesterol)
  • Asking for symptoms of chest pain, dyspnea, palpitations, leg swelling; assess for edema in the extremities 
  • Taking vital signs
  • Inspection (jugular vein distention, peripheral or central cyanosis)
  • Palpation (carotid artery pulses, precordium, peripheral pulses)
  • Auscultation (heart sounds)  
  • Check capillary refill

Heart sounds assessment 

Heart sounds are noises generated by the closing and opening of the heart valves and the resultant turbulent flow of blood. They provide important information about the heart’s function and potential valve problems. 

Normal heart sounds

Heart soundCardiac cycle phaseLocation best heardCaused by
S1SystolicCardiac apexMitral and tricuspid valves closing
S2DiastolicRight upper sternal borderAortic and pulmonic valves closing
S3DiastolicCardiac apexRapid filling of ventricles
Table: Normal heart sounds

Abnormal heart sounds

Heart soundCardiac cycle phaseLocation best heardCaused by
S4DiastolicCardiac apexOccurs at or after S1 and ends beforeor at S2
Systolic murmurSystolicLeft upper sternal borderOccurs at or after S1 and ends beforeor at S2
Diastolic murmurDiastolicLeft midclavicular areaThe heart relaxing in between beatsafter S2 and before S1
Pericardial rubSystolic and diastolicLeft sternal borderParietal and visceral pericardial layers rubbing together
Ejection clickSystolic or diastolicVariesMaximal opening of the aortic or pulmonary valves
Table: Abnormal heart sounds

Heart assessment points

The heart assessment points, also known as the cardiac auscultatory areas, are specific locations on the chest where the nurse or healthcare provider listens to the heart sounds. These areas correspond to the optimal spots to hear specific valves and the flow of blood through the heart. The main assessment points are:

  • Aortic area: 2nd intercostal space at the right sternal border
  • Pulmonic area: 2nd intercostal space at the left sternal border
  • Erb’s point: 3rd intercostal space at the left sternal border
  • Tricuspid area: 4th or 5th intercostal space at the left sternal border
  • Mitral area: at the apex of the heart, usually in the 5th intercostal space at the midclavicular line

Cardiovascular assessment nursing documentation

Below is a template containing the most important points to include in the documentation of a heart assessment: 

Documentation partContentExample
HistoryChief complaint, history, medications, allergies, habitsPatient complains of chest pain for 2 hours
Vital signsBlood pressure, heart rate, rhythm, resp rate and oxygen saturationBP: 120/80 mmHg
HR: 78 bpm, regular
General appearanceAny signs of distress, cyanosis, or fatigueRespirations at 26/min
InspectionJugular venous distension?
Any deformities or abnormal movements in chest wall?
Symmetrical chest wall
PalpationDescribe quality and amplitude of peripheral and carotid pulsesRadial pulse 2+ and regular
AuscultationDocument normal and additional heart soundsS1 and S2 noted, clear and distinct.
Grade II/VI systolic murmur heard at mitral area. 
Edema assessmentPresence, location, degree2+ pitting edema noted on bilateral lower extremities
Capillary refillTime taken for color to returnCapillary refill > 2 seconds
Diagnostic resultsAttach any ECGs or labs
Patient statementsSubjective informationPatient states pain reduced to 2/10 after nitroglycerin
Plan and interventionsMedications, further tests, actions taken 
Table: Documenting a heart assessment

Assessment for heart failure

Specific symptoms to monitor when checking for heart failure include: 

  • Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
  • Fatigue
  • Swelling/peripheral edema
  • When listening to heart sounds, check for S3, murmurs, or gallops
  • Palpate for liver enlargement or ascites
  • Auscultate lungs for signs of fluid accumulation
  • Watch daily weights (sudden gain might indicate fluid retention)
  • Be mindful of any limitations in ADLs 


Heart Assessment 

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Nursing Cheat Sheet

An overview of normal and abnormal heart sounds, such as murmurs and clicks

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