Cardiovascular system

Anatomy of heart
Pathway of Blood Through the Heart and Lungs
Coronary Circulation: Arterial Supply
 Heart Physiology

 Impulse passes from atria to ventricles via

the atrioventricular bundle (bundle of
His)
 AV bundle splits into two pathways in the
interventricular septum (bundle branches)
1. Bundle branches carry the impulse toward the
apex of the heart
2. Purkinje fibers carry the impulse to the heart
apex and ventricular walls
 1-Electrocardiography

Electrical activity is recorded by

electrocardiogram (ECG)
P wave corresponds to depolarization of SA
node
QRS complex corresponds to ventricular
depolarization
T wave corresponds to ventricular
repolarization
Atrial repolarization record is masked by the
larger QRS complex
 2-Cardiac Output (CO) and Reserve

Cardiac Output is the amount of blood

pumped by each ventricle in one minute
 CO is the product of heart rate (HR) and stroke
volume (SV)
 HR is the number of heart beats per minute
 SV is the amount of blood pumped out by a ventricle with
each beat
COCO (ml/min) = HR (75 beats/min) x SV (70
ml/beat)
CO = 5250 ml/min (5.25 L/min)
3-Regulation of Heart Rate: Autonomic Nervous System

Sympathetic nervous system (SNS)

stimulation is activated by stress, anxiety,
excitement, or exercise
Parasympathetic nervous system (PNS)
stimulation is mediated by acetylcholine and
opposes the SNS
 4-Chemical Regulation of the Heart

The hormones epinephrine and thyroxin

increase heart rate
Intra- and extracellular ion concentrations
must be maintained for normal heart function
 Physical examination

The heart is examined indirectly by

inspection, palpation, percussion,
and auscultation of the chest wall. A
systematic approach
. Examination of the chest wall is performed
in the following six areas
 1. Aortic area—second intercostal space to the right of the
 sternum.
 2. Pulmonic area—second intercostal space to the left of
the
 sternum
 3. Erb’s point—third intercostal space to the left of the
sternum
 4. Right ventricular or tricuspid area—fourth and fifth
intercostal spaces to the left of the sternum
 5. Left ventricular or apical area—the, location on the
 chest where heart contractions can be palpated
 6. Epigastric area—below the xiphoid process
 inspection

Is the patient in acute distress?

Is breathing labored or easy?
Is there use of accessory muscles?
Is there cyanosis? Pallor?
Inspect nails.
Inspection of the Chest Wall
Look for edema (pitting and non-pitting)
Observe color
Have the patient lie down for 5 minutes and
measure BP and pulse
Have patient stand and repeat reading
immediately. Allow 90 seconds for maximum
orthostatic changes
A drop in systolic BP of 20 mmHg or
more when standing is orthostatic BP
There is usually an increase in HR
Grasp both radial arteries,
Determine rhythm. The slower the rate, the
longer you should palpate.
If the rhythm is irregular, is there a pattern
to the irregularity?
Observe Jugular Venous Pulse
 Percussion

 Chest Percussion
 Normally, only the left border of the heart can be detected by
 percussion.
 It extends from the sternum to the midclavicular line in the
third to fifth intercostal spaces.
 The right border lies undethe right margin of the sternum
and is not detectable.
 Enlargement of the heart to either the left or right usually
can be noted.
 In people with thick chests, obesity, or emphysema, the heart
may
lie so deep under the thoracic surface that not even its left
border
can be noted unless the heart is enlarged. In
such cases, unless the nurse detects a
displaced apical impulse and suspects cardiac
enlargement,
 Palpation

Stand on the right side of the patient with

him sitting. Place fingertips at 5th ICS, MCL
and you should feel
Palpate all 4 cardiac areas
Any condition that increases the rate of
ventricular filling can produce a palpable
impulse
 General Principles of Auscultation

Never listen through any kind of clothing

Listen at all 4 cardiac areas:
 Aortic --2nd ICS, R
 Pulmonic---2nd ICS, L
 Mitral--cardiac apex, 5th ICS, MCL
 Tricuspid---left lower sternal border
 Principles of Auscultation, con’t

Normally only the closing of valves can be

heard.
Closure of the tricuspid and mitral valves (AV
valves) produce the 1st heart sound.
Closure of the aortic and pulmonic valves
produce the 2nd heart sound.
 Heart Sound

Third HS When AV valves open, the period of

rapid filling of ventricles occurs.
 At the END of rapid filling, a 3rd heart sound
may be heard
 Murmurs

They are produced when there is turbulent

blood flow within the heart
Turbulence may be due to a narrowed
opening of a valve (stenosis) or a valve that
does not close completely, allowing blood to
slosh backwards (regurgitation or
insufficiency)
 Fourth Heart Sound

At the end of diastole,

If the left ventricle is stiff and non-compliant,
you will hear an S4.
 Friction Rub

These are extra-cardiac sounds of short

duration that have a sound like scratching on
sandpaper
May result from irritation of the pericardium
from infection, inflammation, or after open
heart surgery
Best heard when patient sits and holds
breath
 The Physical Examination of blood
vessels

 Inspect for symmetry of extremities

 Examine arterial pulses
 palpate!
 Should not be able to palpate abdominal pulse
unless very thin.
 Get abdominal ultrasound. Often too late when
bulging mass felt.
Palpate abdomen deeply but gently for a mass with
laterally expansive pulsation
Listen for bruits over major arteries with patient
lying flat. Listen 2 inches above umbilicus for
presence of aortic bruit
Renal artery bruits may be heard about 2 inches
above umbilicus and 1-2 inches laterally from mid-
line
Palpate femoral pulse. The lateral corners of the
pubic hair triangle is where you will find the pulse.
Feel both femorals so you can judge equality
Palpate popliteal pulse…often hard to feel.
Place thumbs on patella and press remaining
fingers of both hands in popliteal fossa. Have
legs in mid-flexed position
Palpate dorsalis pedis (top of foot) and
posterior-tibial pulse (inside ankle bone)
Occlude the radial artery by firm pressure.
Ask patient to clinch his fist, then open the
fist and observe the color of the palm
Then compress ulnar artery, clinch fist, and
observe color of palm
Pallor of the palm during compression of one
artery indicates occlusion of the OTHER
artery!
. Normally,
reperfusion occurs within 3 seconds, as evidenced
by the return of color.
• Vascular changes from decreased arterial
circulation include decrease in quality or loss of
pulse, discomfort or pain, paresthesia, numbness,
decrease in temperature, pallor, and loss of
movement. During the first few hours after
invasive
cardiac procedures (eg, cardiac catheterization),
affected extremities should be assessed for
vascular changes frequently.
Hematoma, or a localized collection of clotted
blood in the
tissue, may be observed in patients who have
undergone invasive
. Major blood vessels of the arms and legs are
selected for catheter insertion.
• Peripheral edema is fluid accumulation in
dependent areas of the body (feet and legs,
sacrum in the bedridden patient).
Assess for pitting edema
by pressing firmly for 5 seconds with the
thumb over
the dorsum of each foot,.
Pitting edema is graded as absent or as
present.
• Clubbing of the fingers and toes implies
chronic hemoglobin.
• Lower extremity ulcers are observed in
patients with arterial or venous insufficiency
description of differentiating characteristics
 CARDIAC LABORATORY TESTS

WBCs
Electrolyte(Na-K+-Ca) or renal function test
Blood Urea and createnine -blood glucose
Liver function test
Thyroid Function Tests
CARDIAC ISOENZYMES
TROPONIN I and T
 ELECTROCARDIOGRAM
(EKG or ECG)

Cardiac rhythm
Chamber enlargement
Conduction abnormalities
Electrolyte and toxic disorders
 Peaked T-waves = Hyperkalemia
 QT prolongation = toxic drug effects
 CHEST X-RAY (CXR)

Heart size
Calcification on valves and arteries
Evidence of CHF
 Pulmonary vascular congestion
 Pleural effusions
Masses
 ECHOCARDIOGRAM
(ECHO)

Structural Abnormalities
Chamber sizes
Valvular function
Left ventricular function
 STRESS TESTING

Exercise Treadmill testing

Myocardial Perfusion Imaging (MPI)
Stress Echocardiogram
All done to evaluate for myocardial
ischemia
RADIONUCLIDE ANGIOGRAPHY
COMPUTED TOMOGRAPHY
(CT)
CARDIAC CATHETERIZATION
ABG
 Cardiac Signs and Symptoms

Patients with cardiovascular disorders

commonly have one or more
of the following signs and symptoms:
• Chest pain or discomfort (angina pectoris,
MI, valvular heart disease)
• Shortness of breath or dyspnea (MI, left
ventricular failure, HF)
• Edema and weight gain (right ventricular
failure, HF)
Palpitations (dysrhythmias resulting from
myocardial ischemia, valvular heart disease,
ventricular aneurysm, stress, electrolyte
imbalance)
• Fatigue (earliest symptom associated with
several cardiovascular disorders)
Dizziness and syncope or loss of
consciousness (postural
hypotension, dysrhythmias, vasovagal effect,
cerebrovascular disorders)
Not all chest discomfort is related to
myocardial ischemia.
When a patient has chest discomfort,
questions should focus on differentiating a
serious, life-threatening condition such as MI
from conditions that are less serious or that
would be treated differently