By: Cissette S.

Ricardo, RN, MSN

Objectives:
At the end of the discussion, the
students should be able to:
Discuss the different assessment
parameters for cardiac functioning.
Describe nursing care of clients
undergoing diagnostic tests to assess
cardiac functioning
Describe treatment modalities for clients
with cardiac disorders

Explain the pathophysiology, clinical

manifestations and collaborative

management of cardiac disorders
Design a nursing care plan for clients
with cardiac disorders
Teach client with cardiac disorders
about prevention, management and
rehabilitation factors that optimize
health.

Assess the client for clinical

manifestations associated with

peripheral vascular disorders
Discuss the etiology, risk factors, basic
pathophysiology and clinical
manifestations of peripheral vascular
disease
Develop plan of care for the prevention,
collaborative management and
rehabilitation of clients with peripheral
vascular disease

Implement nursing interventions that

optimize quality of life of clients with

peripheral vascular disorders
Evaluate planned outcomes, using
outcome criteria developed in the
planning phase of care
Conduct nursing history and physical
assessment of the client with an actual
or potential hematologic disorder
Teach a client about diagnostic studies
used to detect hematologic disorder

Discuss risk factors, basic pathophysiology

and clinical manifestations of hematologic

disorders
Design a plan of care for the prevention,
collaborative management and rehabilitation
of clients with hematologic disorders
Implementing nursing interventions that
optimize the quality of life of clients with
hematologic disorders
Evaluate planned clients outcomes, using
outcome criteria developed in the planning
phase of care

BLOOD VESSELS
Which blood circulates from the heart includes :
Arteries thick elastic walls to accept the pulsatile

systolic flow of oxygenated blood away from the heart

Arterioles have thin less elastic walls that are
sensitive to changes in oxygen and wastes, and
constrict or dilate correspondingly (a main
determinate of BP)
Capillaries very thin walls through which the
exchange of cellular wastes and nutrients takes
place.
Venules obtain blood from the capillaries and
deposit it into veins.
Veins thin valvular walls through which
deoxygenated blood returns to the heart.

BLOOD
The circulatory system is the route by which the

cells in your body get the oxygen and nutrients

they need, but blood is the actual carrier of the
oxygen and nutrients
Blood is made mostly of plasma, which is a
yellowish liquid that is 90% water.
But in addition to the water, plasma contains salts,
sugar (glucose), and other substances. And, most
important, plasma contains proteins that carry
important nutrients to the bodys cells and
strengthen the bodys immune system so it can
fight off infection.

The average man has between 10 and 12 pints

of blood in his body. The average woman has

between 8 and 9 pints.
To give you an idea of how much blood that is, 8
pints is equal to 1 gallon (think of a gallon of
milk).
WHAT IS BLOOD?
Blood is actually a tissue. It is thick because it is
made up of a variety of cells, each having a
different job. In fact, blood is actually about 80%
water and 20% solid.

We know that blood is made mostly of plasma. But

there are 3 main types of blood cells that circulate
with the plasma:
Platelets - which help the blood to clot. Clotting
stops the blood from flowing out of the body when
a vein or artery is broken. Platelets are also called
thrombocytes.
Red blood cells - which carry oxygen. Of the 3
types of blood cells, red blood cells are the most
plentiful. In fact, a healthy adult has about 35
trillion of them. The body creates these cells at a
rate of about 2.4 million a second, and they each
have a life span of about 120 days. Red blood cells
are also called erythrocytes.

White blood cells - which ward off infection. These

cells, which come in many shapes and sizes, are

vital to the immune system. When the body is
fighting off infection, it makes them in everincreasing numbers. Still, compared to the number
of red blood cells in the body, the number of white
blood cells is low. Most healthy adults have about
700 times as many red blood cells as white ones.
White blood cells are also called leukocytes.
Note:
Blood also contains hormones, fats,
carbohydrates, proteins, and gases.

FUNCTIONS:

Blood carries oxygen from the lungs and nutrients

from the digestive tract to the bodys cells. It also

carries away carbon dioxide and all of the waste
products that the body does not need. (The
kidneys filter and clean the blood.) Blood also:
Helps keep your body at the right temperature
Carries hormones to the bodys cells
Sends antibodies to fight infection
Contains clotting factors to help the blood to
clot and the bodys tissues to heal

BLOOD TYPES:

There are 4 different blood types:

A, B, AB, and O.
Genes that you inherit from your parents (1

from your mother and 1 from your father)

determine your blood type.
Blood is always being made by the cells inside
your bones, so your body can usually replace
any blood lost through small cuts or wounds.
But when a lot of blood is lost through large
wounds, it has to be replaced through a blood
transfusion (blood donated by other people).

In blood transfusions, the donor and

recipient blood types must be

compatible.
People with type O blood are called
universal donors, because they can
donate blood to anyone, but they can
only receive a transfusion from other
people with type O blood.

BLOOD TEST FOR CARDIOVASCULAR

CONDITIONS:

Certain blood tests can be performed to see if there

is a problem with your heart, lungs, or blood
vessels.
1.Cardiac enzyme tests - which measure the cardiac
enzyme levels in the blood.
Certain enzymes will be present if the heart
muscle (myocardium) has been damaged by a
heart attack, because damaged heart cells
release these enzymes into the blood.
The most common cardiac enzyme that is
released is creatine kinase.

2. Troponin tests - which measure the amount

of troponin (a type of protein) in the blood.
Troponin affects how the heart muscle
contracts.
If there are high levels of troponin in the
blood (troponin T or troponin I), there is
most likely damage to the heart muscle.
The amount of troponin released into the
blood correlates with the degree of
damage to the heart muscle.

3. Arterial blood gas studies - which measure how

well the blood is being oxygenated in the lungs.
4. Lipoprotein (cholesterol) profile - which
measures how much fat or lipid is in the blood.
5. Blood cultures - which can be used to determine
if there are microorganisms (like the bacteria that
causes endocarditis) in the bodys system.
After the blood is drawn, it is placed on a
culture, which helps the bacteria grow.
The bacteria is then analyzed to determine
what type it is and what medicines can be used
to kill it.

6. Blood clotting tests - which measure the bloods

ability to clot.
Clotting stops the blood from flowing out of the
body when a vein or artery is broken
OTHER EXAMINATIONS:
1.Review of Medical History and Physical Exam
2.EKG or ECG
3.Chest X-Ray
4.Echocardiogram
5.Cardiac Catherization
6.Cardiac Perfusion Scan
7.Other Blood Test (Cholesterol etc.)

VASCULATURE OF THE ARM

VASCULATURE OF THE LEG

VASCULATURE OF THE HEAD

CARDIOVASCULAR SYSTEM (TORSO)

The one-way circulatory system carries

blood to all parts of your body. This process

of blood flow within your body is called
circulation.
Arteries carry oxygen-rich blood away from
your heart, and veins carry oxygen-poor
blood back to your heart.
In pulmonary circulation, though, the roles
are switched. It is the pulmonary artery that
brings oxygen-poor blood into your lungs
and the pulmonary vein that brings oxygenrich blood back to your heart.

ANATOMY OF THE HEART

The heart weighs between 7 and 15 ounces

(200 to 425 grams)

Little larger than the size of your fist.
By the end of a long life, a person's heart may
have beat (expanded and contracted) more than
3.5 billion times.
In fact, each day, the average heart beats
100,000 times, pumping about 2,000 gallons
(7,571 liters) of blood.
Your heart is located between your lungs in the
middle of your chest, behind and slightly to the
left of your breastbone (sternum)

It is four chambered, palpable at the 5th

intercostal space.
It is encased in the pericardium
(pericardial sac), made up of a visceral
(inner) layer and a parietal (outer) layer.
Pericardial space is located between
layers of pericardial sac, providing
lubrication to decrease friction with
each contraction.

4 CHAMBERS
Right atrium receives deoxygenated
blood from the body.
Right Ventricle receives blood from
the right atrium
Left Atrium receives oxygenated
blood from the lungs
Left Ventricle receives blood from the
left atrium.

HEART LAYERS:
Endocardium (inner layer)
Myocardium (middle, muscular layer)
Epicardium (outer layer)
CARDIAC VALVES:
Atrioventricular (AV) Valve
Tricuspid and Mitral Valves it prevents blood
from flowing back into the atria during ventricular
diastole.
Semilunar Valve
Pulmonic and Aortic Valve it prevents blood
from flowing back into the ventricles diastole.

THE HEART VALVES

Four valves regulate blood flow through your heart

The tricuspid valve regulates blood flow between

the right atrium and right ventricle.

The pulmonary valve controls blood flow from the
right ventricle into the pulmonary arteries, which
carry blood to your lungs to pick up oxygen.
The mitral valve lets oxygen-rich blood from your
lungs pass from the left atrium into the left
ventricle.
The aortic valve opens the way for oxygen-rich
blood to pass from the left ventricle into the aorta,
your body's largest artery, where it is delivered to
the rest of the body

Heart Sounds

S1 when closure of the AV valves

(tricuspid & mitral) & ventricles

contract
S2 when closure of the semilunar

valves ( pulmonic & aortic) &

the ventricles relax

EXTRA HEART SOUNDS

S3 This occurs immediately after S2
Why? Resistance to filling of ventricles
Note: also called a ventricular gallop
*It is caused by overload.
* use diaphragm (it is a high sound)
S4 - This occurs at the end of diastole, just
before the next S1.
Why? The atrium contract & push blood into
a non-compliant ventricles.
Note: also called an atrial gallop
*caused by HTN, CAD, Aortic stenosis,
cardiomyopathy
* Use bell to listen as it is a low sound.

MURMURS

Caused by turbulence

Therefore we hear a gentle blowing,

swooshing sound.
Why?
1. Velocity of blood increases
(e.g.. exercise, thyrotoxicosis)
2. Velocity of blood decreases (e.g.. anemia)
3. Structural defect in the valves or an
unusual
opening occurs in the chambers

GRADING OF MURMURS
Use VI point grading scale & record as a fraction
(i.e.. I/VI or II/VI)
Grades:
Grade I barely audible, heard only in a quiet room & then
with
difficulty
Grade II clearly audible, but faint
Grade III moderately loud, easy to hear
Grade IV loud, associated with a thrill palpable on the chest
wall
Grade V very loud, heard with one corner of the stethoscope
lifted
off the chest wall
Grade VI loudest, still heard with the entire stethoscope lifted
off
the chest

THE CONDUCTION SYSTEM

Electrical impulses from your heart muscle (the

myocardium) cause your heart to beat (contract)

This electrical signal begins in the sinoatrial (SA)
node, located at the top of the right atrium
The SA node is sometimes called the heart's
"natural pacemaker." When an electrical impulse
is released from this natural pacemaker, it
causes the atria to contract
The signal then passes through the
atrioventricular (AV) node. The AV node checks
the signal and sends it through the muscle fibers
of the ventricles, causing them to contract.

CONDUCTION SYSTEM

HEART CONTRACTILITY

THE HEART BEAT

(Two-part Pumping Action)

As blood collects in the upper chambers (the

right and left atria), the heart's natural

pacemaker (the SA node) sends out an
electrical signal that causes the atria to
contract. This contraction pushes blood
through the tricuspid and mitral valves into the
resting lower chambers (the right and left
ventricles). This part of the two-part pumping
phase (the longer of the two) is
called diastole.

The second part of the pumping phase begins

when the ventricles are full of blood. The

electrical signals from the SA node travel along
a pathway of cells to the ventricles, causing
them to contract. This is called systole
As the tricuspid and mitral valves shut tight to

prevent a back flow of blood, the pulmonary and

aortic valves are pushed open. While blood is
pushed from the right ventricle into the lungs to
pick up oxygen, oxygen-rich blood flows from the
left ventricle to the heart and other parts of the
body.

After blood moves into the pulmonary artery and

the aorta, the ventricles relax, and the pulmonary

and aortic valves close. The lower pressure in the
ventricles causes the tricuspid and mitral valves to
open, and the cycle begins again
This series of contractions is repeated over and

over again, increasing during times of exertion and

decreasing while you are at rest.
The heart normally beats about 60 to 80 times a

minute when you are at rest, but this can vary. As

you get older, your resting heart rate rises.

Your heart does not work alone, though.

Your brain tracks the conditions around you

climate, stress, and level of physical
activityand adjusts your cardiovascular
system to meet those needs.
The human heart is a muscle designed to

remain strong and reliable for a hundred

years or longer. By reducing your risk factors
for cardiovascular disease, you may help
your heart stay healthy longer.

SYSTOLE (Contraction)
Occurs when blood is ejected from the
ventricles.
DIASTOLE (Relaxation)
Occurs when ventricles are at rest.
CARDIAC OUTPUT =SV (stroke volume) X HR
Measures the efficiency of the heart. The amount
of blood ejected from each ventricle in 1 minute.
Average adult CO 4to8 liters/minute.
STROKE VOLUME measures the amount of
blood ejected from the ventricle with each heart
beat.

FACTORS AFFECT CARDIAC OUTPUT:

Heart Rate regulated by the autonomic
nervous system.
Stroke volume which is affected by:
Pre-load The volume of blood in the
ventricle before contraction.
After load the resistance against which
the left ventricle must pump
Contractility force of contraction, which
can increase SV by improving ventricular
emptying.

HEART CONTRACTILITY

BLOOD CIRCULATION OF THE HEART

BLOOD CIRCULATION OF THE HEART

Regulation of Cardiovascular System:

1. Autonomic Nervous System (ANS)
Sympathetic NS
Increases heart rate and force of
contractility
Stimulates the hearts beta adrenergic
receptors for epinephrine and
norepinephrine.
Parasympathetic NS
Decreases heart rate
Stimulates the vagus nerve

2. Baroreceptors (located in the aortic arch and

left and right carotid arteries)
Perceive pressure changes in the arterial
system, responding with messages to the
brainstem.
Results in appropriate increased or decreased
heart rate, and constriction and vasodilation via
the ANS in order to compensate.
Monitor the blood pressure of the blood being
delivered to the brain.
Baroreceptors can identify the changes in the
blood pressure which can increase or decrease
the heart rate.

3. Chemoreceptor (located in the aortic arch

and carotid body)
Perceive chemical changes in the blood (eg.
Decreased in O2 and CO2)
Results in vasoconstriction
4. Renal System
Senses when blood flow to the kidneys
decrease resulting in sodium and water being
retained and release of hormones to further
retain fluids
5. Others (Exercise, Emotion, Temperature)

Cardiovascular Assessment:
1. Health History
Past health history
Medications (past, present, OTC,
herbal)
Surgeries/procedures
Subjective examination (detailed
description of any symptoms from the
client; onset, description, activity,
intolerance, dyspnea, orthopnea).

2. Physical Examination:
Inspection
General activity level, color, alertness, pain,
dyspnea, vital signs, presence of distended neck
veins.
Thorax
Visible scars from previous surgery; normal skin
color
Thorax symmetrical with no visible pulsation
(pulsation of the aortic arch or innominate arteries
maybe observe as normal).
Angle of Louis (raised notch where the
manubrium and body of the sternum are joined at
the 2nd intercostal), maybe use as marker to count
for intercostal spaces.

Peripheral check for edema, cyanosis,

wounds, uneven hair distribution, pain.

Palpation
Skin should be warm, dry
Point of maximum impulse (PMI) maybe
palpated at the 5th intercostal space at the
midclavicular line)
Abdominal aorta may be visibly and palpably
pulsing as normal.
Peripheral
Feet normally have pedal pulses present
Capillary refill time should be <3 seconds.

Percussion
Right sided heart border should not be

distinguishable.
Auscultation (ausculatory areas)
AV 2nd ICS to the right of the sternum
PV 2nd ICS to the left of the sternum
TV 4th ICS left of the sternum
MV (Apex) 5th ICS at the left midclavicular
line
Murmurs are heard when there is a
turbulent blood flow through normal or
abnormal valves.

OTHER LABORATORY STUDIES OF CVD

1. Creatitine Kinase (CK)
It elevated after striated muscle damage
2. CK-MB (Myocardial Bands) and Troponin
It elevated after cardiac muscle damage
It used for ruling out MI
3. Cholesterol
Blood lipid
Elevation is CV risk factor
4. Triglycerides
Fatty acids
Elevation is CV risk factor

5. Lipoproteins (HDL, LDL)

Specific breakdown helpful for determining
CV risk factors.
6. Potassium, Magnessium
Electrolytes high or low levels may interfere
with cardiac rhythm.
7. Heparin Level (PTT Partial thromboplastin
time)
It evaluates coagulation sequence
Heparin level guides appropriate IV dosing for
heparin

8.International Normalized Ration (INR) PT

Prothrombin time
It evaluates coagulation sequence
Elevated level desired to prevent clots for
those at risk.
Normal level required before the client has
invasive procedure (to prevent bleeding)
9. Hemoglobin Level (Hgb)
Needed to transport oxygen to cells and
remove carbon dioxide.
Decrease level may exacerbate angina

10. C-Reactive Protein

Inflammatory marker
Elevation may indicate increased risk for plaque
rupture
11. Sodium
Decrease may indicate fluid overload in heart failure
12. White Blood Cells (WBC)
Elevation may indicate infection (bacterial
endocarditis)
Commonly elevated after an MI
13. Calcium
Elevation may shorten QT interval and cause cardiac
dysrhytmias.

14. Medication Levels (digoxin,

quinidine)
Evaluates therapeutic drug levels
Subtherapeutic or excessive levels
may necessitate changes of dosing.

OTHER DIAGNOSTIC EXAM FOR CVD

(CARDIAC MONITORING)

1. ECG (Electrocardiogram)
It is used to trace electrical activity of the
heart detected on the body surface.
It is also helpful in detecting cardiac
dysrhytmias, cardiac ischemia, MI, and
many other conditions.
2. Holter Monitoring
It is a reading of ECG rhythm for 24 to 48
hours on an outpatient basis.

3. CXR Chest X-Ray

X-Ray visualization to examine the lung fields,
size of the heart, and any fluid around the heart
4. Exercise Treadmill Test (Graded exercise test)
Client walks on treadmill or rides and exercise
bike while being monitored for ECG rhythm and
vital signs in order to assess (CAD) or left
ventricular function.
5. Echocardiogram
UTZ waves picked up by a transducer placed on
different position over the chest wall - to assess
flow of blood, congenital heart defects, estimates
left ventricular function.

6. Stress Echocardiogram
Combination exercise treadmill and
echocardiogram to compare resting images
with immediate post exercise - to assess for
change in left ventricular wall motion and
thickening.
7. Transesophageal Echocardiogram (TEE)
A probe with transducer tip is swallowed by
the client.
Visualization for valvular abnormalities,
possible thrombus, bacterial endocarditis,
congenital heart defects.

NUCLEAR CARDIOLOGY
1. THALLIUM
A radioactive isotope is injected IV so that the
scintillation camera can count radioactive uptake (areas
of poor uptake indicates infarction)
It is useful for assessing the extent of disease in CAD
and predict the effectiveness of bypass surgery or
angioplasty.
2. DIPYRIDAMOLE THALLIUM
Is injected to vasodilate coronary arteries so increase
blood flow will make scanning with thallium more
effective.
Used when the client is unable to tolerate exercise such
as with severe PVD (peripheral vascular dse.)

3. Cardiac Catherization
Insertion of a catheter into the heart via a
vein (for the right side of the heart) or
femoral or brachial artery (for the left side of
the heart)
Useful for obtaining measurement of
ventricular function and diagnosis of CAD
4. Coronary angiogram
Dye is injected to provide further
assessment of structure and motion of the
heart.

5. Percutaneous Coronary Intervention (PCI)

It is an attempt to correct the blockage in the
artery can be made.
TYPE:
Angioplasty blocked area of an artery is
ballooned open, with plaque left pressed around
the walls of the artery.
Angioplasty with stent after blockage is
ballooned, a mesh stent is left in placed to help
support the walls of the blood vessels to stay
open.
Atherectomy plaque is shaved off by rotating
blade.

6. Intracoronary UTZ
Tiny UTZ probe inserted into the coronary artery.
It provides evaluation for plaque size and
consistency, artery walls, and effectiveness of
treatment.
7. Electrophysiology Study (EPS)
Invasive study to assess the electrical activity of the
heart using catheters inserted via the veins to the
right side of the heart
8. Pacemaker
Medical device that takes over the function of a
clients malfunctioning SA node or AN node.

9. Coronary Artery Bypass Graft Surgery (CABG)

Surgical Placement of new conduits to provide
coronary artery blood flow when existing
coronary arteries are not patent. (not open)
10.Peripheral Arteriography and Venography
Injection of radiopaque dye to check the
patency of arteries or veins in the extremities
(usually the legs)
Serial X-Rays done to assess for occlusion,
atherosclerotic plaques, aneurysms, traumatic
injury.

Nursing Diagnosis:
Ineffective tissue Perfusion:
Cardiopulmonay
Decrease Cardiac output
Risk for Activity Intolerance
Acute Pain
Anxiety

Sample Question: No. 1

Which of the following is a priority for the
nurse to report when obtaining a history
from the client scheduled for a coronary
angiogram?
A.) A history of Rheumatic Heart disease
B.) A history of allergy in shellfish
C.) A recent diagnosis of hyperlipidemia
D.) A previous coronary angioplasty to the
right coronary artery.

Answer: B
Rationale:
While obtaining a clear record of the clients cardiac
history it is important prior to a coronary angiogram, It
is priority to notify the physician of an allergy to
shellfish. The client with shellfish allergy is more likely
to be allergic to the contrast dye used in the
procedure. The chart should be marked for an allergy
to shellfish.
Example medication if allergy:
Diphenhydramine (Benadryl)
Steroids and extra IV fluids

Sample Question No. 2

A client is scheduled for a dipyridamole
(Persantine) thallium-201 scan. A nurse
would assess to make sure that the client
avoided which of the following before the
procedure?
A.) Milk products
B.) Caffeine
C.) Excess sugar
D.) Fatty Meal

Answer: B
Rationale:
The test is an alternative to the exercise
thallium 201 scan. The dipyridamole
(persantine) dilates the coronary
arteries as exercise would. Before the
procedure, any form of caffeine should
be withheld, as should aminophylline
and theophylline. Aminophylline may
decrease the effects of dipyridamole.