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Structure of the Heart

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Coronary Arteries

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Blood Supply

LMCA -L side of the heart Circumflex - lateral wall & posterior wall of LV - Occasionally: interventricular septum & SA/AV nodes LAD - anterior wall - apex - anterior VS of LV

RCA -R side of the heart -Inferior wall of the LV -Posterior septal wall -SA & AV nodes

Electrophysiologic Properties
Excitability- ability to depolarize in response to stimulus Automaticity ability of cardiac pacemaker to initiate an impulse spontaneously and repetitively Contractility- ability to contract Refractoriness- inability to respond to a new stimulus while still in a state of depolarization Conductivity- ability of heart fibers to propagate electrical impulses along and across cell membrane

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Cardiac Conduction System

Electrical Activity of the Heart

Electrical impulses from your heart muscle (the myocardium) cause your heart to beat (contract).

S-A node (sinoatrial node) A-V node (atrioventricular node)

Bundle of His
Purkinje system

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Electrical Pathway
STEP 1. The S-A node (natural pacemaker) creates an electrical signal

STEP 2. The electrical signal follows natural electrical pathways through both atria. The movement of electricity causes the atria to contract, which helps push blood into the ventricles

STEP 3. The electrical signal reaches the A-V node (electrical bridge). There, the signal pauses to give the ventricles time to fill with blood.

STEP 4. The electrical signal spreads through the Bundle of His and Purkinje system. The movement of electricity causes the ventricles to contract and push blood out to your lungs and body

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CO= SV x HR
Control of heart rate
Autonomic nervous system and baroreceptors

Autonomic Nervous System Affectation of the CVS 1. Parasympathetic Release of Acetylcholine 2. Sympathetic Release of Norepinephrine

Depolarization Repolarization

(2) Phases: 1. Systole 2. Diastole

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Factors affecting cardiac performance

Preload: pressure generated at the end of diastole; depends on both heart and vascular system the amount of filling of the ventricle during relaxation Afterload: resistance to ejection during systole; depends on both heart and vascular system - the force that opposes ejection of blood from the heart; for the LV, this is the aortic systolic pressure

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Depolarization.

Ventricular pressure Blood flow into the PA & Aorta

S1
(lub)

S2
Blood flow from SVC & IVC into the Atria & Ventricles

(dub )

3
.Repolarization

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Control & Regulation

Regulatory Mechanisms 1. 2. 3. 4. ANS Receptors Hormones Others

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SNS PSNS

Norepinephrine

Acetylcholine Contractility HR

Contractility HR/BP CO Vasoconstriction

Peripheral Baroreceptors, Stretch/Mechanoreceptors and Chemoreceptors

Baroreceptors Decreased HR Mechanoreceptors Increased HR Vasoconstriction Chemoreceptors Increased HR

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Hormonal Influences
Posterior Pituitary Gland
Inhibition of ADH Increased UO/Diuresis Decreased Blood Volume Decreased BP

Kidney
Conversion of Renin

Angiotensinogen
Angiotensin I & II Vasoconstriction Increased BP Release of aldosterone Increased Water & Na retention / Decreased UO Increased BV

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Histamine vasodilation of small blood vessels Bradykinin vasodilation of superficial blood vessels Serotonin vasoconstriction of superficial arterioles & vasodilation of capillaries Lactic acid vasodilation

ASSESSMENT of the CARDIOVASCULAR SYSTEM

I. Risk Factors A. NON-MODIFIABLE RISK FACTORS 1. AGE 55 y/o. Effects of Age- related changes in cardiovascular sx become more pronounced Symptomatic C.A.D. appears predominantly in clients over 40y/o Clients in their 30s, and even in their 20s sometimes suffer from anginal attacks or M.I 50% of Attacks occur in individual >65y/o

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2. GENDER Men are at a greater risk for the development of CVD Risk for women increases significantly at menopause 3. RACE Black Americans have a higher risk for developing CVD than the general population because of their high incidence of HPN. 4. FAMILY HISTORY The presence of Coronary Atherosclerosis in a parent or sibling under 50y/o is associated w/ the same findings in another family member.

B. MODIFIABLE RISK FACTORS

1. CIGARETTE SMOKING Major contributing factor of CVD adult smokers have a 70% higher mortality rate than non-smokers All smokers have more than 2x the risk of attack than the non-smokers Smoking triples the risk of MI in women and doubles the risk of MI in men.

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2. HYPERTENSION over 45y/o and with BP 140/90 & adult w/ BP 160/95 have a 50% chance of mortality HPN can be prevented through adherence to medical regimen 3. SERUM CHOLESTEROL (HYPERLIPIDEMIA) Hyperlipidemia es the risk of developing C.A.D. among clients w/cholesterol level of >300mg/dl; is 3x more likely to develop C.V.D than in clients with <200mg/dl of cholesterol level A diet high in saturated fat, cholesterol and calories is thought to be a major factor in the development of hyperlipidemia

4. DIABETES MELLITUS Diabetes leads to early atherosclerosis Clients w/ DM are at much risk for CAD 5. OBESITY workload & O2 demand of the heart Associated w/ ed caloric intake and elevated levels of LDL 6. LACK OF EXERCISE Exercise can improve the efficiency of the Exercise may reduce the risk of CAD by weight, BP & protective lipoprotein HDL Sexual activity

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7. STRESS >Stress stimulates the CVS by the release of Catecholamines Type A personality = found to have 2x risk of developing CVD compared w/ the Type B person

8. ORAL CONTRACEPTIVES Use of oral contraceptives or birth control pills has been associated with an increased risk of CVD
9. DIET Intake of food with Na, Cholesterol, Saturated fat content & caffeine Nurse also assess attitudes toward food Cultural beliefs and economic status can affect the choice of food

10. HABITS Smoking (duration & the # of cigarette sticks daily) Cigarette smoking es the risk of CAD & worsens hypertension Alcohol intake

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PHYSICAL EXAMINATION
A general inspection Assessment of BP, arterial pulses, and jugular venous pulse Percussion, palpation, and auscultation of the heart Evaluation for edema

GENERAL APPEARANCE Begin with inspection. Does the client lie quietly, or is there restlessness or continual moving about? Can the client lie flat, or is only an upright, erect position tolerated? Does the facial expression reflect pain or obvious signs of respiratory distress? Are there signs of significant cyanosis or pallor? Can the client answer questions without dyspnea during the interview?

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LEVEL OF CONSCIOUSNESS What is the clients affect? Are there obvious signs of anxiety, fear, depression, or anger? How does the client react to those in the immediate vicinity, including significant others?
WEIGHT MANAGEMENT daily weight, height, waist circumference BMI

HEAD, NECK, NAILS, AND SKIN

Pay particular attention to the eyes, ear lobes, lips, and buccal mucosa. arcus senilis xanthelasma Central cyanosis indicates poor arterial circulation. Peripheral cyanosis, seen in lips, ear lobes, and nail beds, suggests peripheral vasoconstriction. Blanch Test Schamroths Test Assess skin turgor (elasticity) by lifting a fold of skin Pallor

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ARCUS SENILIS/GERONTOXON
an opaque ring, gray to white in color, that surrounds the periphery of the cornea. It is caused by deposits of cholesterol in the cornea or hyaline degeneration and occurs primarily in older persons

XANTHELASMA
A cutaneous deposition of lipid material that appears in the skin of the eyelids, most commonly near the inner canthi. yellowish, slightly elevated area. benign and chronic condition that occurs primarily in the elderly. may be associated with raised blood cholesterol, high-density lipoprotein and triglyceride levels, leading to heart disease or diabetes.

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PALLOR Result of inadequate circulating blood Characterized by the absence of underlying red tones (browned skin yellowish brown; black skinned ashen gray) Usually evident in areas least pigmentation: conjunctiva, oral mucous membranes, nail beds, palms of the hand, soles of the feet CYANOSIS Bluish discoloration of the skin Usually evident in the: nail beds and buccal mucosa (in dark-skinned, assess the palpebral conjunctiva, palms and soles)

EDEMA

-Inspect dependent areas for edema. BLOOD PRESSURE - Measure BP in both arms initially to rule out dissecting aortic aneurysm, coarctation of the aorta, vascular obstruction, vascular outlet syndromes, and errors in measurement.

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PULSE -If the pulse is irregular, assess for a pulse deficit 0+ = nonpalpable pulse 1+ = weak thready pulse, difficult to palpate +2 = diminished pulse, cannot be obliterated +3 = easy to palpate, full pulse, cannot be obliterated +4 = full bounding pulse RESPIRATIONS -The rate, rhythm, depth, and quality of the breathing pattern. -Auscultate the lungs for the presence of crackles, rhochi (dry rattling), or other abnormal breath sounds.

HEAD AND NECK Neck Veins -Neck vein distention can estimate central venous pressure (CVP). The amount of distention reflects pressure and volume changes in the right atrium. Carotid Arteries -Check and compare the rate, rhythm, and amplitude of the pulses. -Note whether a bruit is present

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CHEST
Precordium -Perform inspection and palpation of the precordium together to determine the presence of normal and abnormal pulsations. -The point of maximum intensity (PMI) or apical impulse is usually seen at the apex. -Right ventricular enlargement can produce an abnormal pulsation that may be seen as a sustained thrust along the left sternal border.
5 cardinal landmarks: Aortic area R 2nd ICS Tricuspid Area -5th ICS L sternal border Pulmonic area L 2nd ICS Erbs point 3rd L ICS Apex 5th ICS midclavicular line

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Heart Sounds -Note the quality (crisp or muffled), intensity (loud or soft), rhythm (irregular or regular), and presence of extra sounds (murmurs). S1 closing of AV valves, depolarization heard best over the tricuspid and mitral area S2 closing of semilunar valves, repolarization, heard best at aortic and pulmonic area S3 occurs in early diastole during rapid filling of ventricles S4 occurs in later stage during atrial contraction and active filling of ventricles

Pericardial Friction Rub Inflammation of the pericardial sac by rubbing together of visceral and parietal pericardium Best heard at the apex Scrathy, grating much like a squeky leather Accentuated when leaning forward or lies prone and exhales

LUNGS Tachypnea Tachypnea, or rapid respirations, is often associated with pain and anxiety accompanying myocardial ischemic pain. Crackles Crackles are high-pitched, noncontinuous sounds.

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ABDOMEN Examination of the abdomen provides information regarding cardiac competence. Inspection and Palpation -Inspection may reveal abdominal distention. -Palpation may confirm the presence of ascites and an enlarged liver.
Auscultation Loud bruits, heard with the bell just over or above the umbilicus, may indicate an aortic obstruction or aortic aneurysm

SYMPTOM ANALYSIS 6 Cardinal Symptoms of CVD

A. Chest pain

B. Irregularities of heart rhythm C. Respiratory Manifestation D. Syncope E. Fatigue F. Weight gain and dependent edema

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Assessing Chest Pain

Chest pain
-Timing

-Quality
-Quantity -Location -Precipitating Factor -Relieving Factor -Associated Manifestaton

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ANGINA
TIME: QUALITY: SEVERITY: LOCATION: MILD Retrosternal (Left-sternum) bilateral(arms, neck & jaw) but usually to the left side 5-15 MINS 30 MINS

MI

SEVERE Radiates

RELIEVING FX: REST, NITROGLYCERIN, O2

B. IRREGULARITIES OF HEART RHYTHM PALPITATIONS

-derived from the Latin palpitare, to throb. Palpitations are uncomfortable sensations in the chest associated with wide range of dysrhythmias. - Question the client about (1) medications; (2) the frequency of palpitations, precipitating factors, and aggravating or relieving factors; and (3) any manifestations such as dizziness or shortness of breath associated with the onset of the palpitations. -Nervousness, heavy meals, lack of sleep, large intake of coffee, tea, alcohol, tobacco, anemia, thyrotoxicosis

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RESPIRATORY MANIFESTATIONS
DYSPNEA = defined as shortness of breath or labored breathing. 1. EXERTIONAL DYSPNEA or Dyspnea on exertion (DOE)- Most common. -It occurs during mild to moderate exercise or activity and disappears with rest. 2. ORTHOPNEA. Orthopnea (difficult breathing) results from an increase in hydrostatic pressure in the lungs when the person is lying flat and is relieved when the person assumes an upright or semivertical position -Ask clients what actions they take to facilitate breathing. 3. PAROXYSMAL NOCTURNAL DYSPNEA. Paroxysmal nocturnal dyspnea (PND) is dyspnea during sleep that awakens the sleeper with a terrifying breathing attack.

D. SYNCOPE - or fainting, is a transient loss of consciousness related to inadequate cerebral perfusion.

E. FATIGUE - Easy fatigability on mild exertion is a frequent problem for clients experiencing cardiac disease;
F. WEIGHT GAIN AND DEPENDENT EDEMA -As the heart fails, or the blood volume expands, fluid accumulates. -Daily weight measurement is important for clients with cardiac problems. G. OTHER ASSOCIATED MANIFESTATIONS g.1 Cyanosis is a subtle bluish discoloration. -Blanch Test g.2 Clubbing of the fingernails is seen in association with significant cardiopulmonary disease. -Schamroths test g.3 Hemoptysis

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Diagnostic Tests
Non Invasive: Nursing Responsibilities: Explain the purpose and procedure to the client; answer question. Schedule of the test. Perform any preliminary care. Promote emotional and physical comfort.

Laboratory Tests
Purpose:
Diagnose a variety of cardiovascular ailments Screen people considered at risk of CVD Determine baseline values Identify concurrent disorders Evaluate effectiveness of interventions

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Preprocedures:
Determine dietary restrictions before test Note time the drug was administered if to obtain serum drug levels. Ask client if he/she is taking blood thinners such as Warfarin Sodium (Coumadin) delays coagulation and requires longer time to hold pressure over venipuncture site Gently invert lab tubes to prevent clotting of specimens for CBC Apply pressure on puncture site.

CBC ordered for all patients with documented or suspected heart disease for evaluation of the overall health status. Cardiac enzymes CK, LDH, Troponin Myoglobin released from the circulation within 1 to 2 hours of infarction. Not recommended if there is evidence of muscle damage, trauma, or renal failure because of greater potential for false positive lab results

Creatinine Kinase 3 isoenzymes: CK MM CK BB CK MB myocardial muscle, elevated within 6 to 8 after onset of MI, maximum levels at 14 to 36 hours and returns to normal after 48 to 72 hours. Samples should be taken immediately on admission and every 6 to 8 hours for the first 24 hours.

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Lactic acid dehydrogenase Normal range: 100 to 225 mu/ml. Onset: 12 hours Peak: 48 hours Duration: returns to normal in 10 to 14 days Troponin (I, C, T) I modulates contractile state C binds calcium T binds I and C Troponin I and T cardiac specific Onset: 4 to 6 hours Duration 4 to 7 days

Serum Lipids Major Classes of Lipoproteins: 1. chylomicrons composed mainly of triglycerides; originated in the intestine 2. Very Low Density Lipoproteins composed of triglycerides; synthesized by the liver 3. Low Density Lipoproteins 50% cholesterol 4. High Density Lipoproteins composed mainly of protein with a modest amount of cholesterol

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Serum electrolytes: Potassium NV: 3.5 to 5 mEq/L Hypokalemia decrease level due to diuretic therapy, vomiting, diarrhea, and alkalosis. Increases cardiac electrical instability, characteristic U wave in ECG Hyperkalemia associated with kidney disease, and endocrine disorders. Characteristic tall T wave on ECG. Sodium NV: 135 to 145 mEq/L Calcium NV: 4.5 to 5.5 mEq/L Hypocalcemia can lead to serious ventricular dysrhythmias, prolonged QT interval and cardiac arrest. Hypercalcemia shortens the QT interval and causes AV block, tachycardia, bradycardia, and cardiac arrest.

Magnesium NV: 1.5 to 2.5 mEq/L

Hypomagnesemia severe cadiac dysrhythmias including ventricular tachycardia, and fibrillation Hypermagnesemia hypotension, bradycardia, and prolonged PR and wide QRS complex.

Phosphorus - NV: 1.2 to 3.0 mEq/L

Hypophosphatemia same w/ hypercalcemia Hyperphosphatemia same w/ hypocalcemia,

Blood Glucose

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ECG graphic representation of the electrical forces within the heart

12 lead ECG

Tracings: P wave depolarization of the atria PR interval the time it takes for the impulse to spread from the atria to the ventricles QRS complex ventricular depolarization T wave ventricular repolarization

Preprocedures: Remove metal objects No pain or electricity Avoid stimulants such as coffee, tea, and smoking 30 minutes to 1 hour before the test. During procedure: Attach the electrodes to the clients skin Precordial leads: V1 (red) 4 ICS right sterna border V2 (yellow) 4 ICS left sternal border V3 (green) in between 2 and 4 V4 (brown) 5th ICS MCL V5 (black) 5th ICS anterior axillary line V6 (violet) 5th ICS MAL

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Limb leads:
Left upper extremity yellow Left lower extremity green Right upper extremity red Right lower extremity - black

Connect the electrodes to the cable

Instruct to lie still, breathe normally and refrain from talking. Post-procedure: Record clients age, weight, and height and medications being taken. Wipe off the gel from clients skin

2. Signal average used to detect impulses called late potentials and if pt. is at risk for Vtach that may result in sudden death

3. Holter Monitoring can be worn for a day or longer, used to detect dysrhythmias that may not appear in routine ECG

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Stress Test
valuable tool in detecting and evaluating CAD
It involves: Using controlled and carefully supervised exercise Evaluating the coronary arteries Nursing Responsibilities: (Prior to the Test) Inform the client about the purpose and risks of the exercise. Obtain a signed consent. Instruct not to eat or smoke for 2 to 3 hours before test,. No alcohol 4 to 6 hours before test Wear appropriate attire No strenuous activity 12 hours prior to test Take the baseline data: ECG at rest, HR client must have a detailed physical exam before testing. ECG is closely monitored by a physician

Post procedure: Monitor BP, HR and rhythm strip fro at least 15 minutes after or until ECG returns to baseline Avoid warm bath Reasons for Terminating the Test: Chest pain of fatigue Greatly increased heart rate Severe hypertension Dyspnea Untoward s/sx of myocardial ischemia/heart failure. d. Chest x-ray (PAL) to determine the size, silhouette and position of the heart

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e. Echocardiography (2D Echo)

Based on the principles of ultrasound Records the structure and motion of a heart area in relation to its distance from anterior chest wall Detects cardiomyopathy, valvular d/o, ischemia, tumor and chamber size

f. MRI
provides the best information on chamber size, wall motion, valvular function and great vessel blood flow

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2. Invasive
Cardiac Catheterization involves the insertion of a catheter into the heart and surrounding vessels to obtain detailed information about the structure and performance of the heart, valves and circulatory system. May include the studies of the right, left side of the heart and coronary arteries.

Indications:
Confirm a diagnosis of heart disease and determine the extent to which the disease has affected the structure and function of the heart Determine congenital anomalies Obtain a clear picture of cardiac anatomy before heart surgery Obtain pressures within the heart chambers and the great vessels (aorta & pulmonary artery) Measure blood oxygen concentration, tension and saturation within the heart chambers Determine Cardiac Output Perform angiography for better coronary artery visualization Obtain endocardial biopsy specimens Allow infusions of fibrolytic agents directly into an occluded coronary artery to restore coronary blood flow

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2 types of Cardiac Catheterization

Right Sided Catheterization Left Sided Catheterization
The catheter can be passed retrograde (backward) from the brachial and femoral artery into the aorta and then to the left ventricle Rarely during Right sided catheterization, the middle or lower third of the atrial septum is punctured and the catheter is passed transeptally into the left atrium

Angiography invaluable tool in cardiac diagnosis and offers a great assistance in understanding heart and vessel disease. Injection of contrast agent via IV at the desired locations under study.

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CINE ANGIOGRAPHY moving pictures are obtained during cardiac catheterization

CORONARY ANGIOGRAPHY contrast material is directly injected to the coronary arteries

Hemodynamic Studies pressures provide information about blood volume, fluid balance and how well the heart is pumping. (CVP, Pulmonary Artery Pressure, Cardiac output measurement, Intra-arterial pressure monitoring)

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Central Venous Pressure

It reflects the pressure under which the blood is returned to the SVC & RA Determined by vascular tone, blood volume, and the ability of the right side of the heart to receive and pump blood Can be measured with a central venous line placed in the SVC or a balloon flotation catheter in the PA Normal CVP pressure is 2-12mmHg

Nursing Interventions
HOB elevated at 45 degrees angle Straining, coughing or any activity that increases intrathoracic pressure produces false high results Patients with ventilator take readings at the point of end expiration Check connections of catheter and attachments to prevent air embolism Check dressing at insertion site to prevent infection To maintain patency of the system, a small amt of fld is delivered under pressure at a constant rate of flow COMPLICATIONS: pneumothorax, phlebitis, air emboli, fld overload, dysrhythmias, sepsis, and micro electric shock

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Pulmonary Artery Pressure

Determines the left ventricular pressure Can assist in determining when the left ventricle is understretched, overstretched, or appropriately stretched. Pulmonary Artery Catheter provides continuous direct monitoring of PA pressure Has 4 lumen: 1. Proximal lumen terminates in the right atrium, allowing CVP measurement, fluid infusion, & venous access for bld. samples. 2. Distal lumen terminates in the PA & measure PA systolic, diastolic & mean pressure, and pulmonary capillary wedge pressure (PCWP) indicator of left ventricular pressure 3. 3rd lumen for inflation & deflation of balloon 4 . 4th lumen (thermistor port) permits measurement of CO

Nsg. Resp: Explain that the procedure will be uncomfortable but not painful Local anesthesia will be given at anesthesia site Catheter is inserted via percutaneous puncture at the brachial, subclavian, jugular or femoral vein. When catheter is wedged, is the most accurate indicator of left ventricular end-diastolic pressure or left ventricular preload. Normal PCWP is 8-13 mmHg. Greater than 18-20mmHg indicates left ventricular pressure (L-sided heart failure) may coincide with congestion. More than 30mmHg edema

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Pulmonary Artery Catheter and Pressure Monitoring System

Arterial Pressure Monitoring System

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Intra-arterial Pressure monitoring

Common method of obtaining BP measurements for acutely ill clients Provides continuous detection of arterial BP via an indwelling catheter for those with decrease CO, fluctuating hemodynamic status, and progressive peripheral vasoconstriction Intraarterial readings are higher 10 mmHg than cuff BP readings

Nursing Interventions
Before the procedure
perform allens test Maintain aseptic technique Check neurovascular status q 2hrs

After the procedure

Apply 5min pressure Maintain intact dressings for 12hrs

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End of Presentation! Thank You!

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