Cardivascular System

Flow of blood

Anatomy and Physiology

o 300 gms, cone shaped, tilted forward and to the left

o Size of a fist
o Located at the mediastinum

Layers

o Pericardium – surrounded by serous membrane

 Parietal – nearest to mediastinal wall
 Visceral – closest to the heart
 Pericardial space – in between parietal and visceral
o Epicardium – nearest to the heart
o Mycocardium – thickest layer, involuntary, striated with z disc
*Sarcomere – functional unit of muscle
o Endocardium

Chamber of the heart

o Atria – thinner wall, divides interatrial septum

o Ventriculum – thicker wall, pumping structure, contracts to eject blood on pulmonary and
systemic circulation; divided by interventricular eptum

Valves

o AV valves: Tricuspid – between RA and RV Mitral - between LA & LV

1st heart sound, loudest in the apex S1
o SL valves: Pulmonary and Aortic
2nd heart sound, loudest in the base S2

Coronary arteries

o Left Coronary Artery – L circumflex, left anterior descending

o Right Coronary Artery – R marginal, posterior interventricular
o Coronary circulation – need constant supply of O2 and nutrients to contract efficiently and
conduct impulse
o Major BV:
o Blood flow through myocardium is greatest during relaxation (diastole) and reduced during
contraction (systole)
o Rapid, prolonged contractions interfere w/ blood supply with heart
Anastomosis

o Between RCA and LOA

o Blood flow through myocardium is greatest during relaxation
o Collateral circulation – alternative source of blood
o When obstruction develop gradually, other capillaries tend to enlarge to metabolic
needs
o Exercise – stimulates its development

RCA – supplies R side of heart and inferior part of LV

o Left anterior descending –anterior wall of ventricles, anterior septum, bundle branches
o Left circumflex – left atrium, lateral, posterior wall of LV

Implications

RCA block -> conduction disturbance of AV node (arryhtmias)

LCA -> impair pumping ability of LV (CHF) *hypotensive -> arrest

Cardiac cycle – alternating sequence of diastole and systole coordinated by cardiac system

Cycle

2 atria relaxed and filling with blood

o AV valve open because of pressure and ventricles relaxed

o Blood flows wit ventricles emptying atria
o Conduction system stimulate atrial muscle to contract forcing any remaining blood into the
ventricles
o Atria relax
o 2 ventricles contract and pressure increase, AV valves close
o All valves closed
o Increase pressure open up SV forced into pulmonary circulation

Heart sounds

Lub (S1) – occurs when AV valve close

Dub (S2) – occurs when LV valve close

Pulse – indicates heart rate

o During ventricular systole -> expands arteries

o Weakness (irregularity in peripheral pulse/radial) indicates problem
o Apical pulse – rate measured at heart itself
o Pulse deficit – difference between apical and radial
 Ex. Coarctation of Aorta

Cardiac output – blood ejected from left ventricle per minute; average 5.6L/min

o CO = stroke volume x heart rate

Stroke volume – blood ejected / heart beat, increased amount of blood returns to heart, heart stretched
more and force contraction and increase proportionately

Preload – venous return

Afterload – resistance to left ventricular ejection (peripheral resistance) *vasoconstriction, inc. BP = inc.
afterload, inc. preload – force ejection

Vascular System Arteries and Veins

Arteries 3 Layers

Arterioles tunica intima – endothelial layer

Capillaries tunica media – smooth muscle

Ventricles tunica adventitia

Valves

Lympathics

Autoregulation

o Localize vasodilation and vasoconstriction regulated by reflex adjustment

o Decrease on pH and O2 and increase CO2 and release chemical mediation -> vasodilation
o Norepinephrine, epinephrine , and angiotensin -> systemic vasoconstriction (alpha 1 receptors)

Blood Pressure – pressure of blood against systemic arterial walls

o Systolic – pressure exerted by blood when ejected by left ventricle

o Diastolic – pressure exerted are relaxed
o BP = CO x PR
o Peripheral resistance affected by – decrease lumen, vasoconstriction, obstruction in BV

BP Control

Baroreceptors Stretch receptors

ADH – vasopressin: water retention Aldosterone – adrenal gland: water/Na retention

Renin Angiotensin Sytem

Properties of Cardicac Muscle

o Automaticity
o Excitability
o Conductivity
o Contractility

Cardiac Condition

o SA node – pacer 60-100 bpm

o AV node – takes over, decrease HR, as much as 40-60 pbm
o Bundle branches – reason for further bradycardia – 20 bpm

Atrial Contraction – depolarization in P wave

Ventricular Contraction – depolarization in ventricles

T-wave – ventricular repolarization (relaxation)

Control of Heart

o Heart rate and force of contraction controlled cardiac control center (medulla)
o Baroreceptors –change in BP, cardiac center, SNS/PNS
o SNS – increase heart rate and contract
o PNS – vagus nerve stimulation, decrease heart rate
o Beta-receptors – decrease BP. –olols

Nursing History
Risk Factors

o Non modifiable – Age, gender, race, heredity

o Modifiable – stress, diet, alcohol, exercise, smoking, hypertension, hyperlipidemia, DM, Obesity,
contraceptive pill, personality type
*metabolic syndrome

Physical Exam

Inspection – skin color, JV distention, respiration, PMI, edema

Palpate – peripheral pulse (+2), apical pulse (sustained not diffused)

Clinical Manifestation

o Dyspnea – on exertion Palipitation

o Orthopnea – Cla Fatigue
o Syncope Chest pain

Diagnostic test

o Cardiac enzyme: CPK- 0-4.77 mg/dl MB – 70-200 IV/L troponin – 0/6 ng/ml,

Myoglobin – 0-85 mg/dl LDH

o Serum lipids
o Electrolytes
o Potassium – inc. ventricular dysrhythmia
o Calcium
o Magnesium – interval wide QRS
o BUN, chest x-ray
o ECG – initial and monitoring of arrhythmias, non invasive

* Holter monitor – worn to read ECG changes while doing activity

* Echocardiograph – refer sound, heart structures and valvular movement

*10-12 mm H2O – CVP + use manometer

Nursing Responsibilities

o Consent
o Explain procedure
o 0 pt of manometer @ level of atrium
o Record initial reading and position
o Change dressing, IV, manometer, and tubing
o Hold breath when catheter changed
Pulmonary Artery Pressure

4 Ports:

Nursing Responsibilities: consent, check baseline VS, supine, adjust transducer @ phlebostatic axis,
observe site

Cardiac Catheterization – passing a catheter to the BV to visualize the inside of the heart, measure
pressures, assess valve, heart function

Cardiac Angiography – contrast dye injected to visualize blood flow and any obstruction

BV in peripheral vessels

Right sided catheterization

o Antecubital/femoral vein
o Measure right atria and ventricular pressure

Left sided catheterization

o Retrograde
o Transported

Pre-procedure

o Consent
o Assess allergies to seafood/iodine
o Document ht and weight
o Baseline VS
o Inform fluttery feeling/warm, flushed feeling desire to cough

Post-procedure

o VS q 30 mins for 2 hrs

o Assess chest pain, dysrhythmias
o Monitor for bleeding
o Keep extremity extended for 4-6 hrs
o CBR for 6-12 hrs, increase fluid

Coronary Heart Disease

o Narrowing or obstruction of 1 or more coronary arteries as a result of atherosclerosis or

arteriosclerosis
 Pathophysiology
Fatty streak
Inflammatory response DVR to injury in the epithelium (smoking, HPN)
Monocyte recruitment
Foam cells
Further inflammation
Fibrous cap
Atheroma / Plaques
Narrowing of coronary arteries
Other causes: vasospasm, myocardial trauma, congestive anomalies, increase O2 demand from
hyperthyroidism, decrease O2 supply from blood loss or anemia

Hyperlipidemia

o Metabolic Syndrome
 Insulin resitance (FBS >100mg/dl) pro thrombotic (high fibrinogen)
 Central obesity (WC: F >35 inches, M 40 inches)
 Dyslipidemia (Tryglycerides >150 mg/dl, HDL <50 mg/dl F, <40 mg/dl M
 BP >130/85
 Pro-inflammatory

Sign and Symptoms

o Norma during asymptomatic period

o Chest pain
o Palpitation *occlusion of R coronary artery, chest pain, arrhythmia
o Dyspnea, cough, hemoptysis
o Syncope *loss of consciousness *L coronary artery due to pump failure

Medical Management

o Nitrates: isordil, imdur

o Antiplatelets
o Anti lipidemics: statins
o Beta adrenergic blockers: olols
o Calcium channel beta blocker: amlodipine
o Surgery: PTCA, Atherectomy, CABG

Nursing Management

o Encourage to reduce risk by modifying lifestyle

o Administer prescribed medications: Hmb-CoA, nicotinic, fibric acid, bile adequate sequetrants
Angina pectoris

o Chest pain resulting from myocardial ischemia, symptoms of existing disease, no necrosis
o Demand vs supply
 Stable – exhausted
 Unstable – even at rest
 Prizmetal – by vasospasm (cold temp)
 Intractable – doesn’t improve 8 to 6
o Causes: exertion, emotion, exposure to cold, excessive smoking, excessive eating

Pain pattern

o Mild to moderate
o Retrosternal – choking, heart burn, pressing, burning, squeezing
o Radiates to neck, jaw, shoulder, arms L for 3-5 mins
o Relieved by rest and nitroglycerine
o Pallor, diaphoresis, palpitate, dizziness
o ECG changes – ST depression, T wave inversion
o Cardiac enzyme – normal

Meds

o Vasodilator
o B-adrenergic blockers
o Calcium block
o Platelet aggregating inhibiters
o Anticoagulants

Medical intervention

o Anticipate hypotension
o Take max 3 doses at 5 minute interval
o SL preparation has burning or stinging sensation
o Avoid alcohol
o Advise client to carry three tabs in his pocket, store nitroglycerine in cool, dry-dark place replace
3-6 months
o Nitropatch applied OD in am, rotating sites, every 8 hrs
o Amount give NGT if patient took Viagra
o Evaluate effectiveness (if not, suspect MI)
Myocardial Infarction

o sudden decrease of O2 due to absence of coronary blood flow results to destruction of

myocardial tissue in regions of the heart
o after 15 minutes – necrosis
o Causes: thrombus, emboli, atherosclerosis
o Location: Left anterior descending artery – anterior septal wall all or both

V1-V4: ECG change anterior (ventricles)

Circumflex artery – posterior wall MI or lateral wall MI (V5-V6)

Right coronary artery – inferior wall MI

Dx studies – total CK levels, cardiac enzyme elevated, AST, ECG: T wave inversion (cause
of hypoxia), ST elevated (zone of injury), pathologic Q wave (zone of infarction)

Assess

o Pain pattern – severe crushing substernal pain,

o Fever
o Nausea and vomiting
o Oliguria
o Pallor, cyanosis

Nursing intervention

o Acute – administer meds

 Morphine, O2, Nitrate, Aspirin
 Lidocaine – antirhythmic
 B-blockers – may decrease BP, decrease HR
 Thrombolytics
 Anticoagulants
o O2 at 2-4 L/min
o Stool softeners
o Liquid, small frequent feedings (decrease fat, cholesterol, salt)
o Emotional support – anxiety, depression, denial
o Semi-fowlers
o Monitors thrombolytic within 24 hrs after, onset of symptoms
o Ff. acute episodes:
 Maintain CBR
 Provide ROM
 Progress to ambulation
 Rehabilitation
  Early activity, 1-2 metabolic activity in task (MET)
 Hospital discharge – 4th day
 ADL’s resume after 6 weeks
 Sex after 4-8 weeks
o Guidelines
 Complications: cardiogenic shock – pumping ability of the LV severely impaired, cardiac
arrhythmia – lack of O2 causes conduction problems

Cardiac Arryhthmia

o Abnormal cardiac rhythm that can be due to automaticity or conduction or both

o Most common complication or major cause of death in MI
o Most common dysfunction in MI – PVC’s
o PVC of >6/min is life threatening
o Predisposing factors: tissue ischemia, hypoxemia, hypoxemia, CNS and PNS influence, lactic
acidosis
o Types: sinus, atrial, ventricular, conduction defects

Arterial Dysrhythmia

o PAC
o Paroxysmal Atrial Tachycardia
o Atrial Flutter
o Atrial Fibrillation
o Medications

Ventricular Dysrhythmia

o PVC
o Ventricular tachycardia, ventricular fibrillation

Pacemakers

o Electric device that cause collector depolarization and cardiac contraction, initiate and maintains
HR, pacing modes – demand, fixed rate

Nursing Interventions

o Place in firm, flat surface

o Apply interface materials
o Grasp paddle only by insulated handles
o Give command to start
o Apply on paddles at pre cordium, other R parasternal area 3rd ICS
 o Indication is CP arrest, clinical death, breathless, pulseness, CPR started <5 mins. After arrest

Congestive Heart Failure

o Inability of the heart to maintain adequate circulation to vest metabolic demands of body
o Cause: hypervolemia, artenosclerosis, MI, valvularproblems
o Types: R CHF (systemic Sx) – fatigue, distended jugular veins, ascites, cyanosis, splitting edema,
hepatomegaly.
L CHF (pulmonary manifestation) – cardomegaly, cough, exertional dyspnea, cyanosis,
weight loss, orthopnea

Management

o Rest
o High fowler’s / sitting ( better lung expansion)
o Decrease Na and fluids
o Meds: Cardiac glycosides – (+) inotrophy – decrease control in effective pumping, (-)
chronotrophy – inc. heart rate
o Digitalis or Digoxin –
o Guidelines
 Check HR, increase K in tube, normal: 0.5 to 2 mg/dl
 Hypocalcemia – digitalis toxicity
 Antidote: digoxin immune tab (digibind), antibodies that binds to digoxin
 Diuretics: H2O and Na secretion
 Loop diuretics: Furosimide
 Potassium sparing: spironolactone
 Guidelines: give in AM, monitor I and O, S/E hypokalemia,
hyponatremia, dehydration, hypotension
o Rotating tourniquet – apply 3 torniquets, inflate cuff 10 mm above diastolic pressure, rotate
every 15 mins., check distal pulse, remove one at a time @ 15 mins. interval