HANDOUT 5 OXYGENATION: The Respiratory and Cardiovascular System PRELIMS

A.

Anatomy of the Cardiovascular System 1. Heart hollow, muscular organ that lies in the mediastinum rests on the diaphragm

a.

Pericardium
-

encases the heart. thin membranous sac containing 20-30 ml serous fluid protects the heart from trauma and friction Epicardium: thin serous outer layer Myocardium: thick muscular middle layer Endocardium: smooth inner layer in contact with blood Right Atrium low-pressure receives systemic venous blood via superior & inferior vena cava Right Ventricle low-pressure receives blood from RA via tricuspid valve ejects deoxygenated blood via pulmonic valve to the pulmonary artery Left Atrium low-pressure receives oxygenated blood from the lungs via four pulmonary veins Left Ventricle high-pressure receives blood from atrium via mitral valve Ejects oxygenated blood to the aorta into systemic circulation AV (Atrioventricular valves ) Tricuspid Valve Mitral valve

b.

Heart Wall

c.

Heart Chambers (separated by a membranous muscular septum)

d.

Heart Valves
-

between right atrium and ventricle between the left atrium and ventricle

Semilunar valves : between ventricles and artery Pulmonic valve between right ventricle and pulmonary artery Aortic valve between left ventricle and aorta Papillary musles Muscle bundles on the ventricular walls Chordae Tendinae: fibrous bands extending from the papillary muscles to the valve cusps propagation of electricall impulses throughout the myocardium (precursor to heart muscle contraction) Electrical Pathways SA (Sinoatrial) Node: pacemaker o initiating rhythmic impulss t 60-100 impulses/minute AV (Atrioventricular) Node : o receives impulses from the SA node, relays them to the ventricles Bundle of His: o conducts impulses from the AV node (RBB & LBB) o RBB and LBB terminate in the Purkinje fibers Purkinje Fibers: o propagate electrical impulses into the endocardium and myocardium

e.

Cardiac Conduction System

-

Electrical Impulse Activity Phases of the electrocardiogram Normal Sinus Rhythm

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HANDOUT 5 OXYGENATION: The Respiratory and Cardiovascular System PRELIMS

f.

Coronary Arteries
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supply the heart with blood Right Coronary Artery supplies blood to the right heart wall Left Main Coronary Artery supplies blood to the left heart

2.

The Vasculature

a.

The Circulatory System

-

Pulmonary Circulation low pressure low resistance right side of the heart pumps blood into the pulmonary circulation Systemic Circulation high pressure high resistance left side of the heart pumps blood into the systemic circulation

b.

Blood Vessels
1.

classified according to size, location and function Arteries large diameter, thick-walled vessels carry blood away from the heart Arterioles small, thick-walled vessels represent the major part of vascular resistance resistance vessels serve as "circulatory stopcocks" control the distribution of blood to various organs. Capillaries extremely small, extremely thin-walled vessels (one cell thick) allow exchange of gases, nutrients, and other small molecules between the blood stream and tissues in capillary hydrostatic pressure/permeability can lead to edema. Venules

2.

3.

4.

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5.

Veins

small thin-walled vessels bring blood back to the heart highly distensible and contain a large fraction of the blood volume large diameter thin-walled vessels bring blood back to heart Distensible and contain a large fraction of the blood volume

B.

Functions of the Cardiovascular Sytem 1. Heart a. Cardiac Output volume of blood ejected by each ventricle in 1 minute (SV x HR) b.

Stroke Volume : amount of blood ejected by the left ventricle with each heart beat Heart Rate : number of heartbeats per minute (60-100)
each complete heartbeat

Cardiac Cycle

Systole : contraction phase Diastole : relaxation (filling phase) results from vibrations caused by valve closure and ventricular filling

c.

Heart Sounds 1st Sound 2nd Sound 3rd Sound 4th Sound

S1, tricuspid and mitral valve closure S2, aortic and pulmonic valve closure S3, Ventricular Gallop Normal below 30 y/o, Pathologic in older (rapid diastole) S4, Atrial Gallop Resistance to diastole due to hypertrophy or injury of ventricular wall

2.

Vasculature responsible for distributing blood to various tissues of the body.

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HANDOUT 5 OXYGENATION: The Respiratory and Cardiovascular System PRELIMS

3.

Neurologic Factors Regulating Heart Function a. Sympathetic Nervous System Stimulation (norepinephrine) arteriolar vasoconstriction HR +inotropic f/x b.

Parasympathetic Nervous System (acetylcholine)

HR

slowed AV conduction

c.

Chemoreceptors (carotid and aortic bodies)

O2/CO2 = HR

d.

Baroreceptors (aortic arch, carotid sinus, vena cava, PA, atria)

HR = BP changes

C.

Assessment 1. Health History a. Chief Complaint Myocardial Ischemia/Infarction Pain (sterna, upper abdomen) belt-squeezing, radiating to shoulders, neck, arms Paroxysmal Nocturnal Dyspnea

Decreased CO2
Fatigue (with or without activity)

Arrythmias/Ischemia
Palpitations rapid & irregular/pounding heartbeat

Sudden Decrease in CO2

Syncope (with or without dizziness)

Peripheral Vascular Diseasse

Intermittent claudication (extremity pain with exercise)

Decreased Peripheral Perfusion

Diaphoresis with clamminess and cyanosis

Compromised Cardiac Function

b. Dyspnea (DOB, SOB) Orthopnea

Heart Failure
Edema/Weight gain greater than 3lb in 24 hours

History for Risk Factors Non-Modifiable Age, incidence post 40 y/o Gender, greater in men but not after menopause Race, mortality greater for nonwhites + Family history of Cardiovascular Disease other illness (diabetic) Minor Factors Personality type Sedentary living Stress (may contribute to the devt of coronary heart disease) Oral Contraceptive Use Modifiable Smoking (2-4x greater risk to CardioVD) High calorie, fat, cholesterol, sugar and sodium diet High serum lipids (Hyperlipidemia), best indicator is HDL:LDL Hypertension (esp. elevated systolic pressure) Obesity, contributes to severity of other factors Sedentary Lifestyle 2. Physical Assessment

a. b.

Vital Signs Inspection

- PR, CR, BP, RR

distress, anxiety, altered LOC

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skin color (pallor, cyanosis) , buccal, peripheral neck vein distention - reflects right atrial pressure (Jugular Vein Pressure, JVD) respirations (dyspnea, orthopnea) presence of edema - fluid volume overload nail clubbing - sign of chronic hypoxia capillary filling - measure of peripheral circulation (less than 3 seconds.) venous stasis or arterial ulcers , check sacrum for those on bed rest varicose veins

c.

Palpation
PMI (Located at 5th intercostal space, Left MCL) if too low indicates enlarged heart Thrills (palpable murmur) thrusts/heaves Peripheral pulses (carotid, brachial, radial, femoral, popliteal, dorsalis pedis, anterior tibial) check all bilateral and compare Grade 0:no puls 1+:weak 2+:normal 3+:increased 4+:bounding temperature - check bilateral

d.

Auscultation
heart rate rhythm heart sounds S1 (lub) and S2 (dub) murmurs swishing sounds in-between heart sounds (Lub-swish-Dub) pericardial friction rub rough, grating sound from inflamed pericardial sac Bruit, murmur heard outside of the heart (carotid, jugular, temporal, abdominal, aortic, renal and femoral arteries) take B/P in both arms, lying, sitting and standing

e.

Pulse Assessment

note whether regular or irregular Regular o evenly spaced, may vary slightly with respiration Regularly Irregular o regular pattern overall with "skipped" beats Irregularly Irregular o chaotic, no real pattern, very difficult to measure rate accurately

Tachycardia o pulse greater than 100 beats/minute Bradychardia o pulse less than 60 beats/minute.

Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest. Tachycardia is a normal response to stress or exercise.

f.

BP Assessment

inflate the cuff to 30 mmHg above the estimated systolic pressure, release slowly. dont use too small a cuff. The pressure will be 10, 20, even 50 mmHg too high Maximum Cuff Pressure - When the baseline is known or hypertension is not suspected, it is acceptable in adults to inflate to 200 mmHg be aware that there could be an ausculatory gap (a silent interval between the true systolic and diastolic pressures).

g.

Perform Respiratory Assessment

cough, crackles, wheezing, hemoptysis, cheyne-stokes respiration

h.

perform Abdominal Assessment

note liver enlargement /ascites, bladder distention, bruits just above the umbilicus

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3.

Laboratory and Diagnostic Tests a. WBC count b. Lipid Profile c. Cardiac Enzymes d. Blood Coagulation e. Chest radiograph f. ECG g. Holter Montoring h. Exercise ECG i. Echocardiography j. Radionuclide Testing k. Cardiac Catheterization l. Arteriography m. Ventriculography n. Central Venous Pressure o. Pulmonary Artery Pressure Pulmonary Artery Wedge Pressure p. Arterial Line

cholesterol:LDL, HDL, trigylcerides (creatinine phosphokinase, troponin, lactate dehdrogenase) prothrombin, partial thromboplasitn heart size hearts electrical activity 24-hour ECG ECG with physical stress cardiac (valvular) structures and fuction ventricular function, myocardial bloodflow chamber pressures and O2 saturation coronary arteries (visualization) ventricles (visualization) filling pressure of right ventricle, cardiac function left heart pressures peripheral arterial pressures

D.

Health Promotion 1. 2. Modifying Risk Factors Preventing Venous Stasis a. Leg Exercises for those with impaired mobility (bed-ridden) contraction of muscles promote blood back to the heart b. Application of Antiembolism Stockings provide varying degrees of compression on different areas of the leg exert external pressure decreasing venous blood from pooling in the extremities MUST fit properly, and be applied in the morning before client has gotten out of bed c. Use of Pneumatic Compression Devices (intermittent or sequential) d. Avoiding Constriction garters, socks with elastic bands, orthopedic casts, leg-crossing Edema Reduction a. Elevation of Limbs-no pressure on points b. Diet Teaching-restrict fat consumption ( 30% of daily caloric intake), limit salt intake c. Fluid Restriction-until balance is restored, monitor I&O fluid retention=If greater than 2L wt gain > 1kg/day Positioning lying flat promotes venous return (heart works harder in the supine than in the upright position) gravity enhances arterial flow hyotensive: elevate legs 20 to 30 degrees

3.

4.

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5.

Pain Management a. Chest Pain stop all activity, rest, sit comfortably, avoid lying flat, administer O2, nitroglycerine SL, assess BP & PR b. Claudication, Peripheral Ischemic Pain not life-threatening but crippling; avoid cold, cigarette smoking Increased Activity & Energy Conservation gradual and progressive refrain using the Valsalva maneuver have constant rest periods space activities Client Teaching recognition of warning signs: perfusion promotion of blood flow & skin integrity avoidance of fatigue Medications explain tx regimen to client and SO, provide written information CPR

6.

7.

8. 9. E.

Nursing Diagnoses 1. 2. 3. Decreased Cardiac Output inadequate blood pumped by the heart to meet metabolic demands of the body (active or high risk) Ineffective Tissue Perfusion (Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) decrease in oxygen resulting in failure to nourish the tissues at the capillary level Activity Intolerance insufficient physiologic or psychological energy to endure or complete required or desired daily activity

F.

Overview of Cardiovascular Alterations 1. Arrhythmias (Dysrhythmia) any sinus rhythm deviating from normal 2. Coronary Artery Disease focal narrowing of large and medium-sized coronary arteries due to plaque formation 3. Myocardial Infarction destruction of myocardial tissue in heart regions abruptly deprived of blood supply (due to coronary blood flow) 4. Heart Failure (left sided or left ventricular & right-sided or right ventricular syndrome of pulmonary or systemic circulatory congestion caused by myocardial contractility ( CO2 to meet oxygen requirements of tissues 5. Acute Pulmonary Edema rapid fluid accumulation in the extravascular lung spaces (alveoli and interstitial) 6. Cardiac Arrest sudden, unexpected cessation of the hearts pumping action and effecting circulation 7. Endocarditis infection of the endocarium or heart valves due to bacteria/organsm invation (acute, subacute, chronic) 8. Pericarditis inflammation of pericardium (acute, chronic) 9. Pacemaker Implantation temporary or permanent electronic device to replace function of SA node pacer is in direct contact of the heart muscle wall, battery operated 10. Hemorrhage loss of a large amount of blood during a short period (internal, external, arterial, venous, capillary) 11. Valvular Disorders of the Heart stenosis (narrowing of the valve opening) regurgitation/insufficiency (failure of valve to close completely)

WAVEFORMS IN ECG TRACINGS: Page 7 of 11

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P wave: The P wave represents the electrical impulse starting in the sinus node and spreading through the atria. Therefore, the P wave represents atrial muscle depolarization. It is normally 2.5 mm or less in height and 0.11 second or less in duration. QRS complex The QRS complex represents ventricular muscle depolarization. The QRS complex is normally less than 0.12 seconds in duration. T wave The T wave represents ventricular muscle repolarization (when the cells regain a negative charge; also called the resting state). It follows the QRS complex and is usually the same direction as the QRS complex. possibly a U wave The U wave is thought to represent repolarization of the Purkinje fibers, but it sometimes is seen in patients with hypokalemia (low potassium levels), hypertension, or heart disease. If present, the U wave follows the T wave and is usually smaller than the P wave. If tall, it may be mistaken for an extra P wave.

SEGMENTS OR INTERVALS IN ECG TRACINGS:

PR interval The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In adults, the PR interval normally ranges from 0.12 to 0.20 seconds in duration. ST segment The ST segment, which represents early ventricular repolarization, lasts from the end of the QRS complex to the beginning of the T wave. QT interval The QT interval, which represents the total time for ventricular depolarization and repolarization, is measured from the beginning of the QRS complex to the end of the T wave. The QT interval varies with heart rate, gender, and age. The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is 65 to 95 beats per minute. If the QT interval becomes prolonged, the patient may be at risk for a lethal ventricular dysrhythmia called torsades de pointes.

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PP interval Measured from the beginning of one P wave to the beginning of the next. The PP interval is used to determine atrial rhythm and atrial rate. RR interval Measured from one QRS complex to the next QRS complex. The RR interval is used to determine ventricular rate and rhythm

THIS PORTION OF THE HANDOUT IS YOUR ADDITIONAL READING ASSIGNMENT SKIN CHANGES ASSOCIATED WITH PATIENTS WHO HAVE CARDIOVASCULAR PROBLEMS:

Pallora decrease in the color of the skinis caused by lack of oxyhemoglobin. It is a result of anemia or decreased arterial
perfusion. Pallor is best observed around the fingernails, lips, and oral mucosa. In patients with dark skin, the nurse observes the palms of the hands and soles of the feet. Peripheral cyanosisa bluish tinge, most often of the nails and skin of the nose, lips, earlobes, and extremities suggests decreased flow rate of blood to a particular area, which allows more time for the hemoglobin molecule to become desaturated. This may occur normally in peripheral vasoconstriction associated with a cold environment, in patients with anxiety, or in disease states such as HF. Central cyanosisa bluish tinge observed in the tongue and buccal mucosa denotes serious cardiac disorders (pulmonary edema and congenital heart disease) in which venous blood passes through the pulmonary circulation without being oxygenated. Xanthelasmayellowish, slightly raised plaques in the skinmay be observed along the nasal portion of one or both eyelids and may indicate elevated cholesterol levels (hypercholesterolemia). Reduced skin turgor occurs with dehydration and aging.

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Temperature and moistness are controlled by the autonomic nervous system. Normally the skin is warm and dry. Under stress,
the hands may become cool and moist. In cardiogenic shock, sympathetic nervous system stimulation causes vasoconstriction, and the skin becomes cold and clammy. During an acute MI, diaphoresis is common. Ecchymosis (bruise)a purplish-blue color fading to green, yellow, or brown over timeis associated with blood outside of the blood vessels and is usually caused by trauma. Patients who are receiving anticoagulant therapy should be carefully observed for unexplained ecchymosis. In these patients, excessive bruising indicates prolonged clotting times (prothrombin or partial thromboplastin time) caused by an anticoagulant dosage that is too high

COMMONLY USED TERMS IN PATIENTS WITH CONDUCTION PROBLEMS

ablation: purposeful destruction of heart muscle cells, usually in an attempt to control a dysrhythmia antiarrhythmic: a medication that suppresses or prevents a dysrhythmia automaticity: ability of the cardiac muscle to initiate an electrical impulse cardioversion: electrical current administered in synchrony with the patients own QRS to stop a dysrhythmia conductivity: ability of the cardiac muscle to transmit electrical impulses defibrillation: electrical current administered to stop a dysrhythmia, not synchronized with the patients QRS complex depolarization: process by which cardiac muscle cells change from a more negatively charged to a more positively charged intracellular state dysrhythmia (also referred to as arrhythmia):disorder of the formation or conduction (or both) of the electrical impulse within the heart, altering the heart rate, heart rhythm, or both and potentially causing altered blood flow implantable cardioverter defibrillator (ICD): a device implanted into the chest to treat dysrhythmias inhibited: in reference to pacemakers, term used to describe the pacemaker withholding an impulse (not firing) P wave: the part of an ECG that reflects conduction of an electrical impulse through the atrium; atrial depolarization paroxysmal: a dysrhythmia that has a sudden onset and/or termination and is usually of short duration PR interval: the part of an ECG that reflects conduction of an electrical impulse from the sinoatrial (SA) node through the atrioventricular (AV) node proarrhythmic: an agent (eg, a medication) that causes or exacerbates a dysrhythmia QRS complex: the part of an ECG that reflects conduction of an electrical impulse through the ventricles; ventricular depolarization QT interval: the part of an ECG that reflects the time from ventricular depolarization to repolarization repolarization: process by which cardiac muscle cells return to a more negatively charged intracellular condition, their resting state sinus rhythm: electrical activity of the heart initiated by the sinoatrial (SA) node ST segment: the part of an ECG that reflects the end of ventricular depolarization (end of the QRS complex) through ventricular repolarization (end of the T wave) supraventricular tachycardia (SVT): a rhythm that originates in the conduction system above the ventricles T wave: the part of an ECG that reflects repolarization of the ventricles triggered: in reference to pacemakers, term used to describe the release of an impulse in response to some stimulus U wave: the part of an ECG that may reflect Purkinje fiber repolarization; usually seen when a patients serum potassium level is low ventricular tachycardia (VT): a rhythm that originates in the ventricles

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