CADIOVASCULAR SYSTEM

Overview of function & structure of the heart

HEART
- Muscular, pumping organ of the body
- Left mediastinum
- Weigh 300 – 400 grams
- Resembles a closed fist
- Covered by serous membrane – pericardium
Pericardium

Parietal layer Pericardial Visceral layer

Fluid – prevent
Friction rub

Layer
1. Epicardium – outermost
2. Myocardium – inner – responsible for pumping action/ most dangerous layer - cardiogenic shock
3. Endocardium – innermost layer
Chambers
1. Upper – collecting/ receiving chamber - Atria
2. Lower – pumping/ contracting chamber - Ventricles
Valves
1. Atrioventricular valves - Tricuspid & mitral valve
Closure of AV valves – gives rise to 1st heart sound or S1 or “lub”
2. Semi lunar valve
a.) Pulmonic
b.) Aortic
Closure of semilunar valve – gives rise to 2nd heart sound or S2 or “dub”
Extra heart Sound
S3 – ventricular Gallop – CHF
S4 – atrial gallop – MI, HPN

Heart conduction system

1. Sino atrial node (SA node) (or Keith-Flock node)
Loc – junction of SVC & Rt atrium
Fx- primary pace maker of heart
-Initiates electric impulse of 60 – 100 bpm
2. Atrioventicular node (AV node or Tawara node)
Loc – inter atrial septum
Delay of electric impulse to allow ventricular filling
3. Bundle of His – location interventricular septum
Rt main Bundle Branch
Lt main Bundle Branch
4. Purkenjie Fiber
Loc- walls of ventricles-- Ventricular contractions

SA node

AV

Purkenjie Fibers
Bundle of His

Complete heart block – insertion of pacemaker at Bundle Branch

Metal – Pace Maker – change q3 – 5 yo

Prolonged PR – atrial fib T wave inversion – MI

ST segment depression – angina widening QRS – arrhythmia
ST – elev – MI

CAD – coronary artery dse or Ischemic Heart Dse (IHD)

Atherosclerosis – Myocrdial injury
Angina Pectoris – Myocardial ischemia
MI- myocardial necrosis

1
ATHEROSCLEROSIS ARTEROSCLEROSIS

- Hardening or artery due to fat/ lipid deposits at tunica - Narrowing or artery due to calcium & CHON deposits at tunica
intima. media.

Artery – tunica adventitia – outer

- Tunica intima – innermost
- Tunica media – middle

ATHEROSCLEROSIS
Predisposing Factor
1. Sex – male
2. Black race
3. Hyperlipidemia
4. Smoking
5. HPN
6. DM
7. Oral contraceptive- prolonged use
8. Sedentary lifestyle
9. Obesity
10. Hypothyroidism
Signs & Symptoms
1. Chest pain
2. Dyspnea
3. Tachycardia
4. Palpitations
5. Diaphoresis
Treatment
P – percutaneous
T – tansluminar
C – coronary
A – angioplasty

Obj:
1. To revascularize the myocardium
2. To prevent angina
3. Increase survival rate

PTCA – done to pt with single occluded vessel .

Multiple occluded vessels
C – coronary
A – arterial
B – bypass
A –and
G – graft surgery

Nsg Mgt Before CABAG

1. Deep breathing cough exercises
2. Use of incentive spirometer
3. Leg exercises

ANGINA PECTORIS - A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT
nitroglycerin, resulting fr temp myocardial ischemia.
Predisposing Factor:
1. sex – male
2. black raise
3. hyperlipidemia
4. smoking
5. HPN
6. DM
7. oral contraceptive prolonged
8. sedentary lifestyle
9. obesity
10.hypothyroidism

Precipitating factors
4 E’s
1. Excessive physical exertion
2. Exposure to cold environment - Vasoconstriction
3. Extreme emotional response

2
 4. Excessive intake of food – saturated fats.

Signs & Symptoms

1. Initial symptoms – Levine’s sign – hand clutching of chest
2. Chest pain – sharp, stabbing excruciating pain. Location – substernal
-radiates back, shoulders, axilla, arms & jaw muscles
-relieve by rest or NGT
3. Dyspnea
4. Tachycardia
5. Palpitation
6. diaphoresis

Diagnosis
1.History taking & PE
2. ECG – ST segment depression
3. Stress test – treadmill = abnormal ECG
4. Serum cholesterol & uric acid - increase.

Nursing Management
1.) Enforce CBR
2.) Administer meds
NTG – small doses – venodilator
Large dose – vasodilator
1st dose NTG – give 3 – 5 min
2nd dose NTG – 3 – 5 min
3rd & last dose – 3 – 5 min
Still painful after 3rd dose – notify doc. MI!

55 yrs old with chest pain:

1st question to ask pt: what did you do before you had chest pain.
2nd question: does pain radiate? If radiate – heart in nature. If not radiate – pulmonary origin

Venodilator – veins of lower ext – increase venous pooling lead to decrease venous return.

Meds:
A. NTG- Nsg Mgt:
1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug.
2. Monitor S/E:
orthostatic hypotension – dec bp
transient headache
dizziness
3. Rise slowly from sitting position
4. Assist in ambulation.
5. If giving NTG via patch:
i. avoid placing it near hairy areas-will dec drug absorption
ii. avoid rotating transdermal patches- will dec drug absorption
iii. avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch

B. Beta blockers – propanolol

C. ACE inhibitors – captopril
D. Ca antagonist - nefedipine
3.) Administer O2 inhalation
4.) Semi-fowler
5.) Diet- Decrease Na and saturated fats
6.) Monitor VS, I&O, ECG
7.) HT: Discharge planning:
a. Avoid precipitating factors – 4 E’s
b. Prevent complications – MI
c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug
d. Importance of follow-up care.

MI – MYOCARDIAL INFARCTION – hear attack – terminal stage of CAD

- Characterized by necrosis & scarring due to permanent mal-occlusion

Types:

1. Trasmural MI – most dangerous MI – Mal-occlusion of both R&L coronary artery

2. Sub-endocardial MI – mal-occlusion of either R & L coronary artery

Most critical period upon dx of MI – 48 to 72h

3
 - Majority of pt suffers from PVC premature ventricular contraction.

Predisposing factors Signs & symptoms Diagnostic Exam

1. sex – male 1. chest pain – excruciating, vice like, visceral pain 1. cardiac enzymes
2. black raise located substernal or precodial area (rare) a.) CPK – MB – Creatinine
3. hyperlipidemia - radiates back, arm, shoulders, axilla, jaw & abd Phosphokinase
4. smoking muscles. b.) LDH – lactic acid dehydrogenase
5. HPN - not usually relived by rest r NTG c.) SGPT – (ALT) – Serum Glutanic
6. DM 2. dyspnea Pyruvate Transaminase- increased
7. oral contraceptive 3. erthermia d.) SGOT (AST) – Serum Glutamic Oxalo-
prolonge 4. initial increase in BP acetic - increased
d 5. mild restlessness & apprehensions 2. Troponin test – increase
8. sedentary lifestyle 6. occasional findings 3. ECG tracing – ST segment increase,
9. obesity a.) split S1 & S2 widening or QRS complexes – means
10. hypothyroidism b.) pericardial friction rub arrhythmia in MI indicating PVC
c.) rales /crackles 4. serum cholesterol & uric acid -
d.) S4 (atrial gallop) increase
5. CBC – increase WBC

Nursing Management
1. Narcotic analgesics – Morphine SO4 – to induce vasodilation & decrease levels of anxiety.
2. Administer O2 inhalation – low inflow (CHF-increase inflow)
3. Enforce CBR without BP
a.) Bedside commode
4. Avoid valsalva maneuver
5. Semi fowler
6. General liquid to soft diet – decrease Na, saturated fat, caffeine
7. Monitor VS, I&O & ECG tracings
8. Take 20 – 30 ml/week – wine, brandy/whisky to induce vasodilation.
9. Assist in surgical; CABAG
10. Provide pt HT
a.) Avoid modifiable risk factors
b.) Prevent complications:
1. Arrhythmias – PVC
2. Shock – cardiogenic shock. Late signs of cardiogenic shock in MI – oliguria
3. thrombophlebitis - deep vein
4. CHF – left sided
5. Dressler’s syndrome – post MI syndrome
-Resistant to medications
-Administer 150,000 – 450,000 units of streptokinase
c.) Strict compliance to meds
- Vasodilators
1. NTG
2. Isordil
- Antiarrythmic
1. Lydocaine blocks release of norepenephrine
2. Brithylium
- Beta-blockers – “lol”
1. Propanolol (inderal)
- ACE inhibitors - pril
1. Captopril – (enalapril)
- Ca – antagonist
1. Nifedipine
- Thrombolitics or fibrinolytics– to dissolve clots/ thrombus

S/E allergic reactions/ uticaria

1. Streptokinase
2. Urokinase
3. Tissue plasminogen adjusting factor

Monitor for bleeding:

- Anticoagulants
1. Heparin 2. Caumadin – delayed reaction 2 – 3 days

PTT PT

If prolonged bleeding prolonged bleeding

Antidote antidote Vit K

4
 Protamine sulfate
- Anti platelet PASA (aspirin)
d.) Resume ADL – sex/ activity – 4 to 6 weeks
Post-cardiac rehab
1.)Sex as an appetizer rather then dessert –
Before meals not after, due after meals increase metabolism – heart is pumping hard after meals.
2.) Position – non-weight bearing position.

When to resume sex/ act: When pt can already use staircase, then he can resume sex.
e.) Diet – decrease Na, Saturated fats, and caffeine
f.) Follow up care.

CHF – CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation.
- Backflow
1.) Left sided heart failure:

Predisposing factors:
1.) 90% mitral valve stenosis – due RHD, aging
RHD affects mitral valve – streptococcal infection
Dx: - Aso titer – anti streptolysine O > 300 total units
- Steroids
- Penicillin
- Aspirin
Complication: RS-CHF
Aging – degeneration / calcification of mitral valve
Ischemic heart disease
HPN, MI, Aortic stenosis

S/Sx
Pulmonary congestion/ Edema
1. Dyspnea
2. Orthopnea (Diff of breathing sitting pos – platypnea)
3. Paroxysmal nocturnal dysnea – PNO- nalulunod
4. Productive cough with blood tinged sputum
5. Frothy salivation (from lungs)
6. Cyanosis
7. Rales/ crackles – due to fluid
8. Bronchial wheezing
9. PMI – displaced lateral – due cardiomegaly
10. Pulsus alternons – weak-strong pulse
11. Anorexia & general body malaise
12. S3 – ventricular gallop

Dx
1. CXR – cardiomegaly
2. PAP – Pulmonary Arterial Pressure
PCWP – Pulmonary CapillaryWedge Pressure

PAP – measures pressure of R ventricle. Indicates cardiac status.

PCWP – measures end systolic/ diastolic pressure
PAP & PCWP:
Swan – ganz catheterization – cardiac catheterization is done at bedside at ICU
(Trachesostomy – bedside) - Done 5 – 20 mins – scalpel & trachesostomy set

CVP – indicates fluid or hydration status

Increase CVP – decrease flow rate of IV
Decrease CVP – increase flow rate of IV
3. Echocardiography – reveals enlarged heart chamber or cardiomayopathy

4. ABG – PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

2.) Right sided HF

Predisposing factor
1. 90% - tricuspid stenosis
2. COPD
3. Pulmonary embolism
4. Pulmonic stenosis
5. Left sided heart failure

5
S/Sx
Venous congestion
- Neck or jugular vein distension
- Pitting edema
- Ascites
- Wt gain
- Hepatomegalo/ splenomegaly
- Jaundice
- Pruritus
- Esophageal varies
- Anorexia, gen body malaise

Diagnosis:
1. CXR – cardiomegaly
2. CVP – measures the pressure at R atrium
Normal: 4 to 10 cm of water
Increase CVP > 10 – hypervolemia
Decrease CVP < 4 – hypovolemia
Flat on bed – post of pt when giving CVP
Position during CVP insertion – Trendelenburg to prevent pulmonary embolism & promote
ventricular filling.

3. Echocardiography – enlarged heart chamber / cardiomyopathy

4.Liver enzyme
SGPT ( ALT)
SGOT AST

Nsg mgt: Increase force of myocardial contraction = increase CO

3 – 6L of CO

1. Administer meds:
Tx for LSHF: M – morphine SO4 to induce vasodilatation
A – aminophylline & decrease anxiety
D – digitalis (digoxin)
D - diuretics
O - oxygen
G - gases

a.) Cardiac glycosides

Increase myocardial = increase CO
Digoxin (Lanoxin). Antidote: digivine
Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure.
b.) Loop diuretics: Lasix – effect with in 10-15 min. Max = 6 hrs
c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine
d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety
e.) Vasodilators – NTG
f.) Anti-arrythmics – Lidocaine

2. Administer O2 inhalation – high! @ 3 -4L/min via nasal cannula

3. High fowlers
4. Restrict Na!
5. Provide meticulous skin care
6. Weigh pt daily. Assess for pitting edema.
Measure abdominal girth daily & notify MD
7. Monitor V/S, I&O, breath sounds
8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote decrease
venous return
9. Diet – decrease salt, fats & caffeine
10. HT:
a) Complications :shock
Arrhythmia
Thrombophlebitis
MI
Cor Pulmonale – RT ventricular hypertrophy
b.) Dietary modifications
c.) Adherence to meds

6
 PERIPHERAL MUSCULAR DISEASE

Arterial ulcers venous ulcer

1. Thromboangiitis Obliterans – male/ feet 1. Varicose veins
2. Reynauds – female/ hands 2. Thrombophlebitis

1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small to medium sized
arteries & veins of lower extremities. Male/ feet

Predisposing factors:
- Male
- Smokers

S/Sx
1. Intermittent claudication – leg pain upon walking - Relieved by rest
2. Cold sensitivity & skin color changes

White bluish red

Pallor cyanosis rubor

3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis

4. Tropic changes
5. Ulcerations
6. Gangrene formation

Dx:
1. Oscillometry – decrease peripheral pulse volume.
2. Doppler UTZ – decrease blood flow to affected extremities.
3. Angiography – reveals site & extent of mal-occulsion.

Nsg Mgt:
1. Encourage a slow progression of physical activity
a.) Walk 3 -4 x / day
b.) Out of bed 2 – 3 x a / day
2. Meds
a.) Analgesic
b.) Vasodilator
c.) Anticoagulant
3. Foot care mgt like DM –
a.) Avoid walking barefoot
b.) Cut toe nails straight
c.) Apply lanolin lotion – prevent skin breakdown
d.) Avoid wearing constrictive garments
4. Avoid smoking & exposure to cold environment
5. Surgery: BKA (Below the knee amputation)

2.)REYNAUD’S PHENOMENON – acute episodes of arterial spasm affecting digits of hands & fingers

Predisposing factors:

1. Female, 40 yrs
2. Smoking
3. Collagen dse
a.) SLE – pathognomonic sign – butterfly rash on face
Chipmunk face – bulimia nervosa
Cherry red skin – carbon monoxide poisoning
Spider angioma – liver cirrhosis
Caput medusae – leg & trunk umbilicus- Liver cirrhosis
Lion face – leprosy

b.) Rheumatoid arthritis –

4. Direct hand trauma – piano playing, excessive typing, operating chainsaw
S/Sx:
1. Intermittent claudication - leg pain upon walking - Relieved by rest
2. Cold sensitivity

7
Nsg Mgt:
a. Analgesics
b. Vasodilators
c. Encourage to wear gloves especially when opening a refrigerator.
d. Avoid smoking & exposure to cold environment

VENOUS ULCERS
1. VARICOSITIES / Varicose veins - Abnormal dilation of veins – lower ext & trunk
- Due to:
a.) Incompetent valves leading to
b.) Increase venous pooling & stasis leading to
c.) Decrease venous return

Predisposing factors:
a. Hereditary
b. Congenital weakness of veins
c. Thrombophlebitis
d. Heart dse
e. Pregnancy
f. Obesity
g. Prolonged immobility - Prolonged standing
S/Sx:
1. Pain especially after prolonged standing
2. Dilated tortuous skin veins
3. Warm to touch
4. Heaviness in legs

Dx:
1. Venography
2. Trendelenberg’s test – vein distend quickly < 35 secs

Nsg Mgt:
1. Elevate legs above heart level – to promote venous return – 1 to 2 pillows
2. Measure circumference of leg muscles to determine if swollen.
3. Wear anti embolic or knee high stockings. Women – panty hose
4. Meds: Analgesics
5. Surgery: vein sweeping & ligation
Sclerotherapy – spider web varicosities
S/E thrombosis

THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation

Predisposing factors:
1. Smoking
2. Obesity
2. Hyperlipedemia
4. Prolonged use of oral contraceptives
5. Chronic anemia
6. DM
7. MI
8. CHF
9. Postop complications
10. Post cannulation – insertion of various cardiac catheters

S/Sx:
1. Pain at affected extremities
2. Cyanosis
3. (+) Homan’s sign - Pain at leg muscles upon dorsiflexion of foot.
Dx:
1. Angiography
2. Doppler UTZ
Nsg Mgt: Pulmonary Embolism:
1. Elevate legs above heart level. - Sudden sharp chest pain
2. Apply warm, moist packs to decrease lymphatic congestion. - Dyspnea
3. Measure circumference of leg muscles to detect if swollen. - Tachycardia
4. Use anti embolic stockings. - Palpitation
5. Meds: Analgesics. - Diaphoresis
Anticoagulant: Heparin - Mild restlessness

8
6. Complication: