A&P Review Exercise

Some references that might be useful in reviewing you A & P and answering this exercise:
1. Brunner textbook
2. A & P books
3. Lehene Pharmacology textbook students find it very useful

The Autonomic Nervous System

The Autonomic Nervous System (ANS) regulates individual organ function and homeostasis, and for the
most part is not subject to ____________ control.
The ANS effects include control of heart _______and force of ___________, _________ and __________
of blood vessels, contraction and relaxation of smooth muscle in various organs, visual accommodation,
pupillary size and secretions from exocrine and endocrine glands.
Autonomic nerves are responsible for the mediation of visceral sensation and the regulation of vasomotor
and respiratory reflexes, for example the baroreceptors and chemoreceptors in the carotid sinus and aortic
arch which are important in the control of heart rate, blood pressure and respiratory activity.
The ANS is divided into two separate divisions called the ________________and ______________
Systems. Most organs are innervated by fibers from both divisions of the ANS, and the influence is
usually opposing.
Responses of major organs to autonomic nerve impulses
Fill in where appropriate:
Organ

Sympathetic System
Identify receptors and effect of
Sympathetic Stimulation

Parasympathetic System
Identify receptors and effect of
Parasympathetic Stimulation

Heart

Receptor: __________
Effect:
Heart rate: _____________
Contractility: ______________
Conduction velocity: _____________

Receptor: ___________
Effect:
Heart rate: _____________
Contractility: ______________
Conduction velocity: ____________

Arteries

Receptor: _____ Effect:____________

Receptor: _____ Effect:____________

Receptor: _____
Effect:____________

Veins

Receptor: _____ Effect:____________

Receptor: _____ Effect:____________

Receptor: _____
Effect:____________

Receptor: _____ Effect:____________

Receptor: _____ Effect:___________

______________________________

Lungs
Kidney

Receptor: _____ Effect:____________

______________________________

Prof. Octaviano 2/07. Rev. 7/07; 8/07, 2/08, 8/11, 3/12, 2/13

____________________________

Liver

Receptor(s): _____________________
Effect(s):________________________
________________________________
________________________________

Glycogen synthesis

Parasympathetic Nervous System

In physiological terms, the parasympathetic system is concerned with conservation and restoration of
energy. The chemical transmitter in the parasympathetic system is ________________. It is also the
neurotransmitter at some sympathetic synapses. Nerve fibers that release this neurotransmitter from their
endings are described as cholinergic fibers.
The main receptor of the parasympathetic system is called _____________. The parasympathetic nerve
that innervates the hear, lungs and veins is the _____________ nerve.
Sympathetic Nervous System and the Cardiovascular System
In contrast to the parasympathetic system, the sympathetic system enables the body to be prepared for
________ or _________. Sympathetic responses include an ________in heart rate, __________ in blood
pressure and __________ in cardiac output, a diversion of blood flow from the skin and splanchnic vessels
to those supplying skeletal muscle, increased pupil size, bronchiolar__________, contraction of sphincters
and metabolic changes such as the mobilization of fat and glycogen.
______________ and _____________ are the main neuron transmitter for the sympathetic system and are
both called catecholamines. Dopamine is another cathecholamine of the sympathetic system.
The sympathetic system receptors are dividend in two main groups, ________ and ________. These are
further subdivided on functional and anatomical grounds. Thus beta1 receptor effect in the heart result in
______________ force and rate of contraction. The beta2 receptor effect on the smooth muscle results in
__________ in the bronchi and blood vessels. The alpha receptor stimulation results in _____________ of
blood vessels and contraction of bladder and anal sphincters.

CARDIAC PHYSIOLOGY
The primary function of the heart is to impart energy to blood in order to generate and sustain an
arterial blood pressure necessary to provide adequate perfusion of organs. The heart achieves this by
____________ its muscular walls around a closed chamber to generate sufficient pressure to propel
blood from the cardiac chamber (e.g., left ventricle), through the _________ valve and into the aorta.
Each time the heart beats, a volume of approximately _________blood is ejected. This is called
_____________ and is expressed in ml/beat. The heart rate is expressed in beats/minute. The cardiac
output formula is: CO = ______ x ________. Therefore, cardiac output is expressed in ml/minute.
Sometimes, cardiac output is expressed in liters/minute.

Prof. Octaviano 2/07. Rev. 7/07; 8/07, 2/08, 8/11, 3/12, 2/13

Ventricular end-diastolic volume (EDV) or pressure is___________________________________

________________________________. The normal EDV is ________ml. Ejection fraction (EF) is
___________________________________. The normal volume ejection with each contraction is
___________________________________, around _________ ml.
Ventricular end-systolic volume (ESV) is_____________________________________________
__________________________. The normal ESV is ________ml.
Preload
Preload can be defined as__________________________________________________________
____________. It is determined by __________ return and residual blood from ejection fraction also
called end-systolic volume (ESV). The preload is related to the chamber volume just prior to
contraction.
Ventricular preload is increased by fluid _________, increased _________ tone, poor ventricular
contractility which increased ESV, increased ventricular chamber size, increased ventricular filing
time due to decreased HR and valvular insufficiency.
Ventricular preload is decreased by fluid__________, decreased ___________ tone, decreased
ventricular chamber and filling (hypertrophy or impaired must relaxation), decreased ventricular filing
time due to increased HR, decreased ventricular afterload and valve stenosis.
Increased preload increases stroke _________, whereas decreased preload decreases stroke
_________ by altering the force of contraction of the cardiac muscle.
Afterload
Afterload can be viewed as ______________________________________________. In simple
terms, the afterload is closely related to the aortic pressure.
Afterload is increased when aortic pressure and systemic vascular resistance are _____________, by
aortic valve stenosis, and by ventricular dilation. When afterload increases, there is an increase in left
ventricle end-systolic volume/pressure (LVEDP) and a ____________ in stroke volume.
Afterload per se does not alter preload directly; however, when afterload increases, SV decreases and
LVESV increases which when added to venous return increases LVEDV and therefore preload.
Therefore, if PVR is decrease, SV is increased, afterload is decreased and preload is decreased. The
result is decreased cardiac workload.
Renin-Angiotensin-Aldosterone System
The renin-angiotensin-aldosterone system (RAAS) plays an important role in regulating
______________ and systemic vascular resistance, which together influence ________ output and
______________. As the name implies, there are three important components to this system: 1) renin, 2)
angiotensin, and 3) aldosterone. Renin, which is primarily released by the _________, stimulates the

Prof. Octaviano 2/07. Rev. 7/07; 8/07, 2/08, 8/11, 3/12, 2/13

formation of ______________ in blood and tissues, which in turn stimulates the release of
______________ from the adrenal cortex.
Renin release is stimulated by:
1. _____________ nerve activation (via 1-adrenoceptors)
2. renal artery hypotension (caused by systemic hypotension or renal artery stenosis)
3. ___________ sodium delivery to the distal tubules of the kidney.
A reduction in __________ pressure causes the release of renin, whereas __________ in arteriole
pressure _________ renin release.
When renin is released into the blood, it acts upon a circulating angiotensinogen to form
_______________. Vascular endothelium, particularly in the lungs, has an enzyme, angiotensin
converting enzyme (ACE), that acts to form angiotensin II (AII).
AII has several very important functions:

____________ vessels thereby increasing systemic vascular resistance and arterial pressure
Acts on the adrenal cortex to release ___________, which in turn acts on the kidneys to increase
sodium and fluid retention
Stimulates the release of vasopressin _____________ hormone from the posterior pituitary,
which __________ fluid retention by the kidneys
Stimulates thirst centers within the brain
Facilitates _____________ release from sympathetic nerve endings thereby enhancing
sympathetic adrenergic function
Stimulates cardiac hypertrophy and vascular hypertrophy

The renin-angiotensin-aldosterone pathway is regulated not only by the mechanisms that stimulate renin
release, but it is also modulated by natriuretic peptides (ANP and BNP) released by the ________ .
These natriuretic peptides acts as an important counter-regulatory system.
Therapeutic manipulation of this pathway is very important in treating ____________ and heart failure.
Atrial and Brain Natriuretic Peptides
Natriuretic peptides (NPs) are involved in the long-term regulation of ________ and ______ balance,
blood volume and ________ pressure. There are two major pathways of natriuretic peptide actions: 1)
vasodilator effects, and 2) renal effects that leads to natriuresis and diuresis.
NPs directly ________ veins (increase venous compliance) and thereby ________ central venous
pressure, which _______ cardiac output by ________ ventricular preload. NPs also ________ arteries,
which _________ systemic vascular resistance and systemic arterial pressure.
NPs affect the kidneys by ________ natriuresis (increased sodium excretion) and __________
(increased fluid excretion).

Prof. Octaviano 2/07. Rev. 7/07; 8/07, 2/08, 8/11, 3/12, 2/13

A second renal action of NPs is that they __________ renin release, thereby __________ circulatory
volume, sodium level resulting in ________ systemic vascular resistance.
Taken together, these actions of NPs ________ blood volume, ________ arterial pressure, ________
central venous pressure, ________ pulmonary capillary wedge pressure, and ________ cardiac output.
NPs acting on sites within the central nervous system also ________ norepinephrine release by
sympathetic nerve terminals. So, natriuretic peptides serve as a counter-regulatory system for the reninangiotensin-aldosterone system.
A recombinant human BNP, or nesiritide, is approved for use in the acute treatment of decompensated
heart failure.
CARDIOVASCULAR SYSTEM
Coronary blood flow occurs mostly during ___________, because during _________ the blood vessels
within the myocardium are compressed. Increased heart rates, which reduce the time for diastole filling,
can _________ the myocardial blood supply and cause ischemia.
In heart failure, the ventricle is __________ able to empty and therefore the intraventricular volume and
pressure is __________ than normal. During diastole, this pressure is transmitted to the ventricular wall
and opposes and reduces coronary flow, especially in the endocardial vessels.
Clinical examination gives a good indication of cardiac function. There are reliable markers of cardiac
output which are easily assessed such as _____________________________________
____________________________________________________________________________.
___________________- when pressure is applied to skin or a finger nail, it goes white. When the pressure
is released, the color rapidly returns within____________ if circulation is normal. However, if peripheral
circulation is poor return is _____________. This could be the result of hypovolemia, poor cardiac output
or impaired _______________ circulation.
Veins return blood from the capillary beds to the heart, and contain 70% of the circulating blood volume,
in contrast to the 15% in the arterial system. Veins act as a reservoir, and __________ tone is important in
maintaining the return of blood to the heart. For example, in severe hemorrhage, the sympathetic
stimulation causes _____________.
The predominant sympathetic influence is _______________ via alpha-adrenergic receptors. However,
the sympathetic system also causes vasodilation via beta adrenergic and cholinergic receptor stimulation,
but only in skeletal muscle. This increased blood flow to skeletal muscle is an important part of the "fight
or flight" reaction, when exercise is anticipated.

Prof. Octaviano 2/07. Rev. 7/07; 8/07, 2/08, 8/11, 3/12, 2/13

CARDIAC ELECTROPHYSIOLOCY
Normal Impulse Conduction
The electrical currents generated by the heart are commonly measured by an array of electrodes placed on
the body surface and the resulting tracing is called an _________________ (ECG, or EKG). As the heart
undergoes _______________ and _________________, the electrical currents that are generated spread
not only within the heart, but also throughout the body.
The _____________________ measures changes in skin electrical voltage caused by electrical currents
generated by the myocardium. The P wave reflects ________________ depolarization, the QRS complex
ventricular __________________, and the T wave ventricular ______________________. During
________________ the myocardium returns to a resting state. The ECG shows heart rate and rhythm and
can indicate myocardial damage.

Electrocardiogram (EKG, ECG)

P wave
The P wave represents the wave of depolarization that spreads from the ___________________
throughout the atria.
The period of time from the onset of the P wave to the beginning of the QRS complex is termed the
___________ interval (the time it takes for the impulse to travel from the ______________, though the
AV node and the bundle of His), which normally ranges from 0.12 to 0.20 seconds in duration. A
prolonged P-R interval (>0.2 sec) indicates some degree of heart block.
QRS complex
The QRS complex represents ventricular ____________________. Ventricular rate can be calculated
by determining the time interval between QRS complexes.
The duration of the QRS complex is normally 0.06 to 0.1 seconds. This relatively short duration
indicates that ventricular depolarization normally occurs very _________________. If the QRS
complex is prolonged (> 0.1 sec), conduction is impaired within the ventricles.
ST segment
The isoelectric period (ST segment) following the QRS is the time at which the entire ventricle is
________________. The ST segment is important in the diagnosis of ventricular _____________ or
__________________.
T wave
The T wave represents ventricular _________________ and is longer in duration than depolarization.

Prof. Octaviano 2/07. Rev. 7/07; 8/07, 2/08, 8/11, 3/12, 2/13

Identify the "typical" ECG tracing shown below. Identify each wave on the small boxes and the
interval in the larger boxes:

interval

interval

_____interval
______
interval

The pacemaker of the heart is the ________________ and it is found in the _____________. Under
normal circumstances, the pacemaker normal rate is 60 to 100 beats per minute. If the SA node fails and
the A-V node takes over, the intrinsic heart rate would be around _______ to ______beats per minute. If
the ventricle takes over, the intrinsic rate would be around _______ to ______ beats per minute.

Regulation of Conduction
The conduction of electrical impulses throughout the heart, and particularly in the specialized
conduction system, is strongly influenced by ______________________ system. Sympathetic activation
________________ conduction, contractility and rate. This positive dromotropic effect of sympathetic
activation results from norepinephrine binding to beta-adrenoceptors, which increases conducivity. This
leads to more rapid depolarization and an increase in the heart ________________ (positive
chronotropic effect) and contractility (positive inotropic effect). Therefore, drugs that block betaadrenoceptors (beta-blockers) may decrease conduction, rate and contractility resulting in a negative
_________________, ___________________, and __________________ effect.
Parasympathetic (vagal) activation _________________ conduction velocity (negative dromotropy) and
_________________ heart rate (negative chronotropy). This leads to slower depolarization.
Acetylcholine, released by the vagus nerve, binds to cardiac muscarinic receptors, which decreases
conduction velocity and heart rate. Excessive vagal activation can produce AV block.
Carotid massage _________________ vagal stimulation resulting in ________________ in heart rate.
Drugs which increase vagal activity causes a ___________________ in heart (negative chronotropic
effect). Drugs that activate the sympathetic receptors cause a positive ____________________ effect
increasing heart rate.

Conduction Defects
If the conduction system becomes damaged or dysfunctional, the individual is said to have a
_____________________. A fast dysrhythmia is called __________________ with a heart hate greater
than 100 beats per minute. A slow dysrhythmia is called ___________________ with a heart rate lower
than 60 beats per minute.
Prof. Octaviano 2/07. Rev. 7/07; 8/07, 2/08, 8/11, 3/12, 2/13

Exercise
1. Identify the chambers of the heart and each valve.
2. A diseased valve that does not close properly is termed valvular ______________.
3. A diseased valve that does not open sufficiently is termed valvular ____________.
4. Describe the layers of the heart.
5. CO = _____ x ______. The normal CO is _______________.
6. Stroke volume is ______________________________________________________
7. Normal strove volume is _____________________.
8. Describe factors that would increase or decrease CO and explain why.

9. What is End Diastolic Volume (EDV)?

10. What would increase or decrease EDV? How would it affect CO?

11. What is ejection fraction (EF)? What is the normal EF? Which clients would have a decrease EF and
why?

12. What is preload? Identifies conditions that would increase or decrease preload and explain why.

13. What is afterload? Identifies conditions that would increase or decrease afterload and explain why.

14. Name the major blood vessels arriving and leaving the heart.

15. Identify factors which may affect the heat rate, describe how they affects it.

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16. Describe the conduction system of the heart.

17. The cells of the heart has what is called an intrinsic automaticity, every cell is able to initiate an
impulse. Is this good or bad? Explain your answer.

18. Describe conditions that decrease coronary flow and explain why.

19. What is pulse pressure? What is pulse deficit?

20. What does pulse pressure and pulse deficit reflect?

21. Describe factors affecting B/P and explain why.

22. What is an auscultatory gap? The unawareness or this gap or improper interpretation of this gap
may lead to? Recommendation to prevent this from happening?

23. Typically, how close is the systolic B/P via palpation to the systolic blood pressure obtained via
auscultation?

24. Which kind of patient would be more likely to have an auscultatory gap it and what are the
implications of having it?
25. How does the body control blood pressure?

26. Which hormones are important in the control of B/P and how do they work?

Prof. Octaviano 2/07. Rev. 7/07; 8/07, 2/08, 8/11, 3/12, 2/13

27. What is the function of calcium in blood vessels and cardiac muscle?

28. Describe the physiology of changes in orthostatic vital signs. What changes are considered normal and
what does it reflect?

29. Describe the proper procedure to assess orthostatic V/S and what would be expected normal.

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