Ncm Doña Remedios Trinidad Romualdez

Medical Surgical Nursing Medical Foundation – College of

112
CARDIOVASCULAR SYSTEM: Review of Anatomy, Assessment and Diagnostics
Nursing
by CHRISTIAN POLENO, RN, MD

Anatomy and Physiology of the Cardiovascular and anterior descending artery and the left
Haemato-Lymphatic System circumflex artery
• Left anterior descending coronary artery is
called as the widow maker.
ANATOMY
• RIGHT CORONARY ARTERY and its branches
Heart supply the right atrium.

• a four-chambered hollow muscular organ normally

about the size of a fist.
• composed of three layers: a thin inner lining, the
ENDOCARDIUM; a layer of muscle, the
MYOCARDIUM (the thickest layer); and an outer
layer, the EPICARDIUM.
• covered by a fibroserous sac called the
PERICARDIUM which consists of two layers namely
the VISCERAL (inner layer) and PARIETAL (outer
layer)
• A small amount of pericardial fluid (10 to 15 mL)
lubricates the pericardial space.
• The heart is divided vertically by septum: interatrial and
the interventricular septum.

LEFT CORONARY ARTERY supplies left atrium, the left

ventricle, the interventricular septum, and a portion of
the right ventricle.

CONDUCTION SYSTEM OF THE HEART

CARDIAC VALVES
• serve to keep blood flowing in a forward direction.
• ATRIOVENTRICULAR VALVES: Tricuspid and
Mitral Valves
• SEMILUNAR VALVES: Aortic and Pulmonic -
prevent blood from regurgitating into the ventricles at
the end of each ventricular contraction.

P-wave represents depolarization of the atria.

QRS Complex represents depolarization from the AV
node throughout the ventricles.
T wave represents repolarization of the ventricles.

CORONARY CIRCULATION

• Blood flow into the two major coronary arteries

occurs primarily during diastole (heart relaxes).
• LEFT CORONARY ARTERY arises from the aorta
and divides into two main branches: the left
 Ncm Doña Remedios Trinidad Romualdez
Medical Surgical Nursing Medical Foundation – College of
112
CARDIOVASCULAR SYSTEM: Review of Anatomy, Assessment and Diagnostics
Nursing
by CHRISTIAN POLENO, RN, MD

The Frank–Starling law is based on the fact that,

The electrical impulse is normally started by the within limits, the greater the initial length or stretch of
sinoatrial (SA) node (the pacemaker of the heart). The the cardiac muscle cells (sarcomeres), the greater the
electrical impulse travels from the atria to the AV node degree of shortening that occurs. This result is caused by
through internodal pathways. The excitation then increased interaction between the thick and thin
moves through the bundle of His and the left and right filaments within the cardiac muscle cells. Preload is
bundle branches. The action potential moves through decreased by a reduction in the volume of blood
the walls of both ventricles by means of Purkinje fibers. returning to the ventricles. (Brunner & Suddarth’s, 14th
ed)
• SYSTOLE - contraction of the myocardium,
results in ejection of blood from the ventricles. Other definition:
• DIASTOLE - relaxation of the myocardium, allows As the volume of blood returning to the heart
for filling of the ventricles. increases, muscle fiber stretch also increases (increased
• CARDIAC OUTPUT (CO) - the amount of blood preload), resulting in stronger contraction and a greater
pumped by each ventricle in 1 minute. CO = SV x stroke volume. This relationship, referred to as the Frank
HR. (normal adult at rest = 5L/min) Starling Law.
• CARDIAC INDEX (CI) - the CO divided by the body
surface area (BSA). VASCULAR SYSTEM
• PRELOAD - the volume of blood in the ventricles
at the end of diastole, before the next ARTERIES AND ARTERIOLES
contraction. • carry oxygenated blood away from the heart.
• AFTERLOAD - the peripheral resistance against • Large arteries have thick walls composed mainly
which the left ventricle must pump. (increased of elastic tissue (responsible for elastic
afterload = seen in individuals with property).
hypertension and large vessel diseases or any • Arterioles serve as the major control of arterial
form of obstruction) BP and distribution of blood flow.
• CO - calculated by multiplying the amount of • elastic property cushions the impact of the
blood ejected from the ventricle with each pressure created by ventricular contraction and
heartbeat—the stroke volume (SV)—by the provides recoil that propels blood forward into
heart rate (HR) per minute. For the normal adult the circulation. Arterioles respond readily to
at rest, CO is maintained in the range of 4 to 8 local conditions such as low oxygen (O2) and
L/min. increasing levels of carbon dioxide (CO2) by
dilating or constricting.

CAPILLARIES
• The thin capillary wall is made up of endothelial
cells, with no elastic or muscle tissue.
• The exchange of cellular nutrients and metabolic
end products takes place through these thin-
walled vessels.

VEINS AND VENULES

• Carry deoxygenated blood toward the heart.
• Veins are large-diameter, thin-walled vessels
that return blood to the right atrium
From SVC and IVF – RA – tricuspid valve – RV -
• The venous system is a low-pressure, high-
pulmonary artery – lungs (to be oxygenated –
volume system.
pulmonary vein (carries oxygenated blood) – left atrium
– mitral valve/bicuspid valve – left ventricle – aorta –
systemic circulation

2 arteries that carries unoxygenated blood:

◼ Pulmonary artery
◼ Umbilical artery (fetal circulation)

FRANK STARLING LAW

 Ncm Doña Remedios Trinidad Romualdez
Medical Surgical Nursing Medical Foundation – College of
112
CARDIOVASCULAR SYSTEM: Review of Anatomy, Assessment and Diagnostics
Nursing
by CHRISTIAN POLENO, RN, MD

ASSESSMENT
SUBJECTIVE DATA

PAST MEDICAL • SYMPTOMS: chest pain,

HISTORY shortness of breath,
fatigue, palpitations,
dizziness with position
changes, syncope,
hypertension,
thrombophlebitis,
intermittent claudication,
varicosities, and edema
• MEDICAL CONDITIONS:
anemia, rheumatic fever,
streptococcal throat
infections, congenital
heart disease, stroke
MEDICATIONS • OVER-THE-COUNTER
(OTC) DRUGS, HERBAL Dyspnea is the subjective experience of breathing
SUPPLEMENTS, AND discomfort that consists of qualitatively distinct
PRESCRIPTION DRUGS: sensations that vary in intensity.
dosage, time of last dose, Hypoxia is a state in which oxygen is not available in
and the patient’s sufficient amounts at the tissue level to maintain
understanding of the adequate homeostasis.
drug’s purpose and side Hypoxemia is defined as a decrease in the partial
effects pressure of oxygen in the blood.
Palpitations is the unpleasant awareness of the
SURGERIES • Specific treatments, past heartbeat.
surgeries, or hospital Paroxysmal nocturnal dyspnea is defined as attacks of
admissions shortness of breath, especially once at night that
• DIAGNOSTIC WORKUPS: awakens the patient.
ECG or a chest x-ray Orthopnea is the sensation of breathlessness in the
FAMILY • Ischemic Heart Disease, recumbent position, relieved by sitting or standing.
HISTORY Respiratory Diseases, Nocturia is defined as the need for patients to get up at
Thyroid Conditions night on a regular basis to urinate.
Syncope is the transient loss of consciousness followed
PERSONAL • Alcohol and tobacco use by recovery.
AND SOCIAL
HISTORY OBJECTIVE DATA

FUNCTIONAL HEALTH PATTERNS VITAL SIGNS Take BLOOD PRESSURE bilaterally

• Health Perception – Health Management Pattern

ORTHOSTATIC HYPOTENSION
• Nutritional – Metabolic
• Elimination ORTHOSTATIC HYPOTENSION is a drop in systolic
• Activity – Exercise blood pressure of atleast 20 mmHg or in diastolic blood
• Sleep – Rest pressure of atleast 10 mmHg within 3 minutes of
• Cognitive – Perceptual standing.
• Self Perception – Self Concept
• Role Relationship TRUE or FALSE? TRUE
• Sexuality – Reproductive If the cuff is too SMALL (narrow), the blood pressure will
• Coping - Stress Tolerance read HIGH; if the cuff is too LARGE (wide), the blood
• Values and Beliefs pressure will read LOW on a small arm and HIGH on a
large arm.
 Ncm Doña Remedios Trinidad Romualdez
Medical Surgical Nursing Medical Foundation – College of
112
CARDIOVASCULAR SYSTEM: Review of Anatomy, Assessment and Diagnostics
Nursing
by CHRISTIAN POLENO, RN, MD

• Differentiate WHITE COAT

HYPERTENSION, MASKED HYPERTENSION
and NOCTURNAL HYPERTENSION
• Review the STEPS IN BLOOD PRESSURE
MEASUREMENT

PERIPHERAL VASCULAR SYSTEM

INSPECTION: hair color, hair distribution, and venous
pattern; check extremities for edema, dependent rubor,
clubbing of nail beds, varicosities and ulcers.

JUGULAR VENOUS PRESSURE

• Closely parallels
pressure in the right atrium,
or central venous pressure
• Best assessed from
pulsations in the right
internal jugular vein
• Usually measured in vertical distance above the
Sternal Angle (of Louis)
• JVP measurements >3 cm above the sternal
angle, or >8 cm above the right atrium is
considered elevated or abnormal. THORAX

JVP Measurement
https://stanfordmedicine25.stanford.edu/the25/neck-
exam-jugular-venous-pressure-measurement.html

PERIPHERAL VASCULAR SYSTEM ◼ AORTIC: 2nd ICS to the RIGHT of the sternum
◼ PULMONIC: 2nd ICS to the LEFT of the sternum
PALPATION: temperature, moisture, pulses and edema; ◼ TRICUSPID: 5th LEFT ICS close to the sternum
pulses in the neck and extremities ◼ MITRAL (apex): LEFT MCL at 5th ICS
◼ ERB’S POINT: 3rd ICS to the LEFT of the sternum
• THRILL is a palpable vibration.
• CAPILLARY REFILL is used to assess arterial flow HEAVES are sustained lifts of the chestwall in the
to the extremities. Return of color after blanching precordial area that can be seen or palpated.
of the nailbed should occur in less than 2 seconds.
APICAL PULSE also known as, POINT OF MAXIMAL
AUSCULTATION: IMPULSE (PMI), lies medial to the to the midclavicular line
in the 4th or 5th ICS.
• BRUIT is buzzing or humming sound heard over a
blood vessel indicating turbulent blood flow.
AUSCULTATION
AUSCULTATION
S1
• Closure of the atrioventricular valves
• Soft “lubb” sound
 Ncm Doña Remedios Trinidad Romualdez
Medical Surgical Nursing Medical Foundation – College of
112
CARDIOVASCULAR SYSTEM: Review of Anatomy, Assessment and Diagnostics
Nursing
by CHRISTIAN POLENO, RN, MD

• Signals the start of systole (myocardial

contraction)
S2
• Closure of the semilunar valve
• Sharp “dupp” sound
• Signals the start of diastole (cardiac relaxation)
• Splitting of S2 (normal among pregnant and
young adults) best heard at the pulmonic area
during inspiration

https://www.youtube.com/watch?v=FtXNnmifbhE&feat • Venous Hum

ure=youtu.be • Pericardial Friction Rub
S3 • Description of murmurs for Patent
• Low intensity vibration of the ventricular walls Ductus Arteriosus, Aortic Stenosis, Mitral
usually associated with decreased compliance of Regurgitation, Tricuspid Regurgitation,
the ventricles during filling. VSD, Aortic Regurgitation, Mitral
• Normally heard among young adults Stenosis
• pathologic in patients with left-sided heart
failure or mitral valve regurgitation RECORDING NORMAL FINDINGS
• Also known as ventricular gallop

S4
• Low frequency vibration caused by atrial
contraction.
• Also known as atrial gallop.
• May be normal in normal older adults with no
evidence of heart disease.
• Pathologic in patients with CAD,
cardiomyopathy, left ventricular hypertrophy, or
aortic stenosis
• Acc to the book: it may be normal in older
adults with no evidence of heart disease
ABNORMAL CVS FINDINGS AND CLINICAL SIGNIFICANCE

https://www.youtube.com/watch?v=o8eqYHCy7dw&fe
ature=youtu.be

GRADING MURMURS
 Ncm Doña Remedios Trinidad Romualdez
Medical Surgical Nursing Medical Foundation – College of
112
CARDIOVASCULAR SYSTEM: Review of Anatomy, Assessment and Diagnostics
Nursing
by CHRISTIAN POLENO, RN, MD

• Sensitive indicator of very

early myocardial injury but
lacks specificity for MI.

Troponin biomarker of choice in the diagnosis

of myocardial infarction (MI).
Creatinine Kinase biomarker of choice to diagnose
reinfarction.

C-REACTIVE PROTEIN
• produced by the liver during periods of acute
inflammation (specific?)
• increased level of CRP is an independent risk
factor for CAD
HOMOCYSTEINE
• Elevated levels of Hcy have been linked to a
higher risk of CAD, peripheral vascular disease,
and stroke.
CARDIA NATRIURETIC PEPTID MARKERS
(remember their locations or the structures that
produce them)
ATRIAL B-TYPE C-TYPE
NATRIURETI NATRIURETIC NATRIURETIC
C PEPTIDE PEPTIDE (BNP) PEPTIDE
(ANP)
DIAGNOSTIC TEST AND PROCEDURES • fro • from the • from
CARDIAC BIOMARKERS m Ventricle endoth
the s elial
Atri • marker of and
TROPONIN • myocardial muscle protein um choice for renal
released into circulation distinguis epitheli
after injury or infarction hing a al cells
• Subtypes: troponin T (cTnT) cardiac or
and troponin I (cTnI) respirato
• detectable within 4 to 6 ry cause
hours of myocardial injury, of
peak at 10 to 24 hours, and dyspnea
can be detected for up to 10
to 14 days
SERUM LIPID
CREATININE • Isozymes specific to skeletal LIPOPROTEINS: TRIGLYCERIDES, CHOLESTEROL and
KINASE muscle (CK-MM), brain and PHOSPHOLIPIDS
nervous tissue (CK-BB), and
the heart (CK-MB) Identify
• Begin to rise 3 to 6 hours
after symptom onset, peak Triglyceride is the main storage form of lipids and make
in 12 to 24 hours, and return up about 95% of fatty tissue.
to baseline within 12 to 48 Cholesterol a structural component of cell membranes
hours after MI and plasma lipoproteins, is a precursor of
MYOGLOBIN • low-molecular-weight corticosteroids, sex hormones, and bile salts.
heme protein found in Phospholipids contain glycerol, fatty acids, phosphates,
cardiac and skeletal muscle. and a nitrogenous compound.
 Ncm Doña Remedios Trinidad Romualdez
Medical Surgical Nursing Medical Foundation – College of
112
CARDIOVASCULAR SYSTEM: Review of Anatomy, Assessment and Diagnostics
Nursing
by CHRISTIAN POLENO, RN, MD

COMPONENTS OF THE LIPID PANEL:

Cholesterol, Triglyceride, LDL (bad cholesterol), and HDL
(good cholesterol)

Normal values:
HDL – >50
LDL – <100 Cardiac Conduction System ECG Basics
Triglyceride (measure of how much fat you eat)- <150 https://www.youtube. https://www.youtube.
Cholesterol - <200
com/watch?v=RYZ4da com/watch?v=xIZQRjk
FwMa8 wV9Q
IMPORTANT POINTS TO REMEMBER:
• Elevations in triglycerides and LDL are strongly Be familiar with the association of P QRS T complex.
associated with CAD.
• An increased HDL level is associated with a EXERCISE OR STRESS TESTING
decreased risk of CAD
• used to evaluate the heart’s response to physical
stress.

• helps to assess CVD and set limits for exercise

• Describe Apoproteins programs.
• Differentiate Chylomicrons, LDLs, HDLs and
ECHOCARDIOGRAM
VLDLs
• uses ultrasound (US) waves to record the
CHEST X-RAY
movement of the structures of the heart.
• radiographic picture of • provides information about abnormalities of (1)
the chest can show valvular structures and motion, (2) cardiac
cardiac contours, heart chamber size and contents, (3) ventricular and
size, and anatomic septal motion and thickness, (4) pericardial sac,
changes in individual and (5) ascending aorta.
chambers.
• Pericardial effusion or pericardial tamponade =
• records any Beck’s triad:
displacement or
enlargement of the heart, extra fluid around the • Hypotension
• muffled heart sounds
heart, and pulmonary congestion.
• distended neck veins
ELECTROCARDIOGRAM

• The basic P, QRS, and T waveforms are used to

assess cardiac activity.

• Deviations from the normal sinus rhythm can

indicate problems in heart function.
 Ncm Doña Remedios Trinidad Romualdez
Medical Surgical Nursing Medical Foundation – College of
112
CARDIOVASCULAR SYSTEM: Review of Anatomy, Assessment and Diagnostics
Nursing
by CHRISTIAN POLENO, RN, MD

CARDIAC MRI

• can detect and find areas of MI in a 3-D view.

• plays a role in prediction of recovery from MI
and in the diagnosis of congenital heart and
aortic disorders and CAD.
• does not require any radiation to the patient.

CARDIAC CT

• heart-imaging test that uses CT technology with

or without IV contrast (dye) to see the heart
anatomy, coronary circulation, and great blood
vessels (e.g., aorta, pulmonary veins, artery).

• The calcium-scoring CT scan is used to find

calcium deposits in plaque in the coronary
arteries.

• Coronary CTA is a noninvasive test used to

diagnose coronary artery stenosis.

CARDIAC CATHETERIZATION

• provides information about CAD, coronary

spasm, congenital and valvular heart disease,
and ventricular function.

• also used to measure intracardiac pressures and

O2 levels, as well as CO and EF.

REFERENCES

• Medical and Surgical Nursing: Assessment and

Management of Clinical Problems by Lewis,
Dirkson et al, 9th edition

• Bate’s Guide to Physical Examination and

History Taking by Lynn S. Beckly, 11th edition

• Harrison’s Principles of Internal Medicine by

Jameson, Fauci, et al, 20th edition