hand-out no. 5 ncm 103

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Ms. April Anne D. Balanon GreywolfRed

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HA DOUT 5 OXY E ATIO :

A. Anatomy of the Cardiovascular System1. 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

b. Heart Wall- Epicardium: thin serous outer layer- Myocardium: thick muscular middle layer- Endocardium: smooth inner layer in contact with blood

c. Heart Chambers(separated by a membranous muscular septum)

- 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

d. Heart Valves- AV (Atrioventricular valves )

Tricuspid Valve between right atrium and ventricle Mitral valve 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

e. Cardiac Conduction System- 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

Electrical Impulse ActivityPhases of the electrocardiogramNormal Sinus Rhythm

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f. Coronary Arteries- 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 Vasculaturea. 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- classified according to size, location and function

1. Arteries large diameter, thick-walled vessels carry blood away from the heart

2. 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.

3. 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.

4. Venules

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small thin-walled vessels bring blood back to the heart

highly distensible and contain a large fraction of the blood volume5. Veins

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)

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

b. Cardiac Cycle each complete heartbeat

Systole : contraction phase Diastole : relaxation (filling phase)

c. Heart Sounds results from vibrations caused by valve closure and ventricular filling

1st Sound S1, tricuspid and mitral valve closure2nd Sound S2, aortic and pulmonic valve closure3rd Sound S3, Ventricular Gallop

Normal below 30 y/o, Pathologic in older (rapid diastole)4th Sound 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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3. Neurologic Factors Regulating Heart Functiona. 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. Assessment1. Health History

a. Chief Complaint

Myocardial Ischemia/Infarction Pain (sterna, upper abdomen) belt-squeezing, radiating to shoulders,

neck, arms

Arrythmias/Ischemia Palpitations rapid & irregular/pounding heartbeat

Peripheral Vascular Diseasse Intermittent claudication (extremity pain

with exercise)

Compromised Cardiac Function Dyspnea (DOB, SOB) Orthopnea

Paroxysmal Nocturnal Dyspnea

Decreased CO2 Fatigue (with or without activity)

Sudden Decrease in CO2 Syncope (with or without dizziness)

Decreased Peripheral Perfusion Diaphoresis with clamminess and

cyanosis

Heart Failure Edema/Weight gain greater than 3lb in

24 hours

b. 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 UseModifiable- 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. Vital Signs - PR, CR, BP, RRb. Inspection

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

Tachycardiao pulse greater than 100 beats/minute

Bradychardiao 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 isacceptable in adults to inflate to 200 mmHg

be aware that there could be an ausculatory gap (a silent interval between the true systolic anddiastolic 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 countb. Lipid Profile cholesterol:LDL, HDL, trigylceridesc. Cardiac Enzymes (creatinine phosphokinase, troponin, lactate dehdrogenase)d. Blood Coagulation prothrombin, partial thromboplasitne. Chest radiograph heart sizef. ECG hearts electrical activityg. Holter Montoring 24-hour ECGh. Exercise ECG ECG with physical stressi. Echocardiography cardiac (valvular) structures and fuction

j. Radionuclide Testing ventricular function, myocardial bloodflowk. Cardiac Catheterization chamber pressures and O2 saturationl. Arteriography coronary arteries (visualization)m. Ventriculography ventricles (visualization)n. Central Venous Pressure filling pressure of right ventricle, cardiac function

o. Pulmonary Artery Pressure left heart pressuresPulmonary Artery Wedge Pressure

p. Arterial Line peripheral arterial pressures

D. Health Promotion

1. Modifying Risk Factors

2. 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

3. Edema Reductiona. Elevation of Limbs-no pressure on pointsb. 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

4. 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

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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 & PRb. Claudication, Peripheral Ischemic Pain

not life-threatening but crippling; avoid cold, cigarette smoking

6. Increased Activity & Energy Conservation gradual and progressive refrain using the Valsalva maneuver have constant rest periods space activities

7. Client Teaching recognition of warning signs:

perfusion promotion of blood flow & skin integrity avoidance of fatigue

8. Medications explain tx regimen to client and SO, provide written information

9. CPR

E. Nursing Diagnoses

1. Decreased Cardiac Output inadequate blood pumped by the heart to meet metabolic demands of the body (active or high risk)

2. Ineffective Tissue Perfusion (Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) decrease in oxygen resulting in failure to nourish the tissues at the capillary level

3. Activity Intolerance insufficient physiologic or psychological energy to endure or complete required or desired daily activity

F. Overview of Cardiovascular Alterations1. Arrhythmias (Dysrhythmia)

any sinus rhythm deviating from normal2. Coronary Artery Disease

focal narrowing of large and medium-sized coronary arteries due to plaque formation3. 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 tissues5. 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 circulation7. 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 operated10. 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:

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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 and0.11 second or less in duration.

QRS complex

The QRS complex represents ventricular muscle depolarization. The QRS complex is normally less than0.12 seconds in duration.

T wave

The T wave represents ventricular muscle repolarization (when the cells regain a negative charge; alsocalled the resting state). It follows the QRS complex and is usually the same direction as the QRScomplex.

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 wavefollows 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 andrepresents the time needed for sinus node stimulation, atrial depolarization, and conduction through theAV node before ventricular depolarization. In adults, the PR interval normally ranges from 0.12 to 0.20seconds 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, ismeasured from the beginning of the QRS complex to the end of the T wave. The QT interval varies withheart rate, gender, and age. The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is65 to 95 beats per minute. If the QT interval becomes prolonged, the patient may be at risk for a lethalventricular 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 determineventricular 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 (pulmonaryedema 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 time is 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 thatsuppresses 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 cardiacmuscle 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 asarrhythmia):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

chestto treat dysrhythmias

inhibited: in reference topacemakers, 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

isusually 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 thatreflects 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 theconduction 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 mayreflect 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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hand-out no. 5 ncm 103

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