Circulation

JoeBeth C. BerGado, RN, LPT

Health Care II
• Pericardium – double layer of • The Heart Wall – 2 layers
fibroserous membrane that that • Endocardium – lining of the
encloses the heart heart chambers & great vessels
• Outermost layer: Function is to
• Myocardium – cardiac muscle
protect the heart and anchor sit to
surrounding structures cells
• Epicardium – Visceral layer, the • This is what contracts with each
heart’s outermost layer heart beat

Cardiac Anatomy
• 2 atria; 2 ventricles form 2
parallel pumps
• Separated by atrioventricular
(AV) valves
• Tricuspid on the right
• Bicuspid or mitral on the left
• Function of the valves is to
prevent backflow
• Ventricles are separated from
the great vessels by the
semilunar valves
• Pulmonic on the right
• Aortic on the left

Cardiac Anatomy
• Example showing open
and closed valves
• The mitral valve is the
only one that has two
leaves; the others each
have three

Cardiac Valves
• Coronary circulation
• Pulmonary circulation
• Systemic circulation
• Arterial circulation
• Venous circulation

Three Circulations
• The heart receives no
nourishment from the
blood within its chambers
• Separate coronary
circulation – coronary
arteries
• Coronary arteries originate
at the base of the aorta and
branch out to encircle the
Coronary
heart

Circulation
• Arteries fill during
ventricular relaxation
• If clogged, the client
may experience chest
pain or angina, or a
myocardial infarction
or heart attack

Coronary
Circulation
Coronary Artery
Blockage
Use to wait for collateral
circulation to develop
Now a balloon may be inserted &
inflated (then removed) to open the
blockage
A stent may be placed. Some
are dissolve over time.
Size of Stents
Or an artery from a different part of
the body may be inserted – bypass
surgery
Cardiac Cycle
Cardiac Cycle – Step
One
• The pulmonary and aortic valves close
• The mitral and tricuspid valves open
• The atria contract and blood flows into the ventricles

Cardiac Cycle – Step

Two
 The cycle then repeats itself.
Cardiac Cycle – Step
Three
• When & what is systole?
• When & what is diastole?

• Diastole is twice as long as systole because diastole is

largely a passive process

Cardiac Cycle
S1 is “lub” & S2 is
“dub”
• S1 – the first heart sound: Beginning of ventricular
systole; closing of the AV valves, which are _____ and
_______
• S2 – the second heart sound: Beginning of ventricular
diastole; closing of the semilunar valves, which are
_______ and _______

Heart Sounds
• Cardiac muscle is the only muscle in the body that can
generate electrical impulses & contract independently
of the nervous system
• This is called automaticity
• Controlled by specialized cells & pathways

Cardiac Conduction
System
• Sino-atrial or SA or
sinus node is the
primary pacemaker of
the heart
• Located where the
SVC enters the RA
• Initiates electrical
impulses that travel
through the heart &
Cardiac Conduction
result in ventricular
contraction
System
• AV impulse travels
through the atria and
converge at the
atrioventricular or AV
node
• This slightly delays the
transmission to the
ventricles; which
allows the atria to
contract slightly before
Cardiac Conduction
the ventricles do

System
• After passing through the
AV node, the electrical
impulses travel down the
septum to the ventricular
conduction pathways
• The bundle of His, the left
& right bundle branches,
and the Purkingje fibers

Cardiac Conduction
System
Cardiac
Conduction
Cardiac Conduction
without the heart muscle
• Stroke volume (SV): • Cardiac output: the
the amount of blood amount of blood pumped
ejected from the by the ventricles in 1
ventricles into minute
circulation with each • Calculated by multiplying
contraction the SV times the HR
• Adults: stroke volume
• CO = SV x HR
is about 70 mL per
beat • Normal CO is 4-8 L/min

Cardiac Output
• Arteries
• Veins
• Capillaries

Three Kinds of
Vessels
Inside wall is very smooth!

Arteries
Veins
Capillaries
Capillaries
 Red Blood Cells
contain hemoglobin, a molecule
specially designed to hold
a biconcave disc that is round
oxygen and carry it to cells that
and flat without a nucleus
need it.

can change shape to an amazing

extent, without breaking, as it
squeezes single file through the
capillaries.
.
Cardiovascular Risk
Factors
• Nonmodifiable risk factors

• Modifiable risk factors

• Nontraditional factors

Cardiovascular Risk
Factors
• Heredity
• Genetic overlay on developing CVD (cardiovascular disease)
• Client is at higher risk if parent with CVD
• African-American at higher risk
• Age
• More prevalent in people > 60, but this is changing
• Gender
• More prevalent in men than women, until women reach
menopause – estrogen has protective effect; then risk is the
same for both

Nonmodifiable Risk
Factors
• Elevated serum lipid levels
• Hypertension
• Cigarette smoking
• Diabetes
• Obesity
• Sedentary lifestyle

Modifiable Risk
Factors
• Metabolic syndrome
• Central obesity
• Increased triglycerides
• Low HDL
• Hypertension
• Elevated fasting glucose level
• C-reactive protein (CRP)
• Inflammatory process with acute MI
• Elevated homocysteine level
• Increased with atherosclerosis
• B –vitamins thought to lower it

Nontraditional
Factors
• Decreased cardiac output
• Impaired tissue perfusion
• Blood alterations

Alterations in
Cardiovascular Function
• May follow a MI, when cardiac muscle dies
• Very irregular, or very high or low heart rates
• Congenital cardiac anomalies
• Heart failure: when the heart is unable to keep up with
demands for oxygen and nutrients
• Follows an MI, or uncontrolled hypertension, or extensive
arteriosclerosis
• Left sided failure: fluid backs up into the pulmonary system
• Right sided failure: fluid backs up into the periphery

Decreased Cardiac
Output
• Atherosclerosis – narrowing & loss of elasticity
• Leads to ischemia – lack of blood supply d/t obstruction
• Vessel inflammation
• Arterial spasm
• Blood clots
• Venous impairment, too
• Clot formation (DVTs, PE [pulmonary embolism])
• Edema

Impaired Tissue
Perfusion
• Hemoglobin issues
• Inadequate RBCs,
• Low hemoglobin levels
• Abnormal hemoglobin structure: What is an example?

• Blood volume – high or low can create an issue

Blood Alterations
• Assessing
• Nursing History
• Physical Assessment
• Diagnostic Studies
• Nursing Diagnoses
• Planning
• Implementing
• Evaluating

Nursing
Management
• Nursing history
• Current & past cardiovascular problems
• Family history of CVD (HTN, increased cholesterol level, heart
attack, stroke)
• Other contributory medical history
• Exercise/activity level
• History of tobacco use
• Diet: fat & salt intake, alcohol intake, caffeine intake
• Presence of symptoms such as pain, SOB, dizziness, fatigue,
palpitations, cough, fainting
• Medications for heart, blood pressure, circulation & cholesterol
• Lifestyle: social support, stressors, methods of coping

Assessment
• Physical Assessment
• Blood pressure – both arms
• Bilateral peripheral pulse assessment
• Apical/peripheral pulse assessment
• Auscultation of carotid arteries for bruits
• Lung sounds
• Skin assessment: color, temperature, hair distribution,
lesions, edema

Assessment
• Diagnostic Studies
• Also used as screening tools to identify factors that
can be modified
• Cardiac monitoring – continuous recording of
heart’s electrical activity – use 2 to 3 leads/views
• Can be done in-patient or out-patient->telemetry
• Electrocardiography (EKG) – 12 leads or views

Assessment
• Diagnostic Studies
• Blood tests:
• Hemoglobin
• Serum electrolytes – especially hyperkalemia and
hypokalemia (POTASSIUM! – 3.5 to 5.3)
• Also, magnesium, calcium, sodium, phosphorous
• Cardiac enzymes: creatine kinase (CK) & troponin –
useful with patients with chest pain; increased when
there is cardiac muscle damage, as when an MI occurs

Assessment
• Ineffective Peripheral Tissue Perfusion
• Risk for Decreased Cardiac Tissue
Perfusion
• Decreased Cardiac Output
• Activity Intolerance
• Pain
• Fear

Nursing
Diagnoses