Chapter 11 – Cardiovascular System Assessment
Brief Scan – Cardiovascular System
A brief scan involves involves assessment of level of consciousness, colour changes, and sometimes pulse and blood pressure. This assessment helps you quickly recognize cues of clinical deterioration and may influence your decision on whether immediate action is required.
Steps of the brief scan include:
1. Assess level of consciousness.
- Does the client have an altered level of consciousness and confusion? Normally, clients should be alert and oriented.
2. Assess colour changes.
- Are there signs of cyanosis or pallor in the lips, mucous membranes, fingernails, or conjunctiva? Cyanosis and pallor result from hypoxemia, and can have many causes including cardiovascular.
3. Assess pulse and blood pressure.
- Is the client’s pulse and blood pressure within the normal range? Is the pulse rhythm regular?
- How does the client’s pulse and blood pressure compare to their baseline?
Contextualizing Inclusivity – Assessing Colour Change
Cyanosis: This is best seen in areas with rich vasculature and thin overlying dermis: mucous membranes/lips, conjunctiva, and extremities (fingernails). In people with darker skin, cyanosis can appear as a grey/white shade around the lips and the conjunctiva can appear as a grey/bluish shade while people with yellowish tones to their skin can have a greyish/green shade (Lewis, 2020; Sommers, 2011). In people with lighter skin, cyanosis appears as a dusky bluish/purple shade (Lewis, 2020).
Pallor: In people with darker skin, this can appear as a grey shade to the mucous membranes/lips, nail beds, and skin, and a yellowish shade in people with lighter brown skin; it can be helpful to look at the palms of people with dark skin when assessing for pallor as they tend to be paler (Lewis, 2020). In people with lighter skin, pallor can appear as a generalized pale discolouration to the skin, nail beds, and mucous membranes/lips. In people of all skin colours, the conjunctiva is normally a healthy pink due to the vascularity, but with pallor it will appear white or very pale pink (Mukwende et al., n.d.).
Priorities of Care
A client who with new onset of altered level of consciousness requires immediate intervention. Although altered level of consciousness can be related to many body systems, it may have a cardiovascular component. For example, the client may be experiencing reduced cardiac output (insufficient blood being pumped by the heart per minute) and a disruption in the normal heart rhythm. It is best to conduct a primary survey to evaluate any signs of clinical deterioration and notify the physician or nurse practitioner of any abnormal findings.
