Cardiovascular System

1. Cardiovascular System Nursing 1120 By: Diana Blum RN MSN Metropolitan Community College

2. Basics • In the mediastinum • Right side is under sternum • About the Size of a fist • Weighs 10-14 oz.

3. Cardiac Function • Primary function : to pump blood through the pulmonary and systemic circulations

4. 3 Layers of Cardiac tissue • Endocardium: • Myocardium: • Epicardium:

6. Blood Flow • Right Atrium: receives blood from vena cava and from coronary arteries • Tricuspid Valve: passes blood from right atrium to right ventricle • Right Ventricle: bottom chamber of the heart that contracts (systole) and pushes blood through pulmonic valve and into pulmonary artery

7. Blood Flow Continued • Pulmonary artery: carries blood to the lungs • Pulmonary veins: carry the newly oxygenated blood back to the heart • Left Atrium: accepts blood from pulmonary veins • Mitral Valve: moves blood from left atrium to left ventricle • Left Ventricle: thickest and strongest muscle • Cone shaped and contains apex of heart • When the LV contracts (Systole) blood is ejected into aorta and out to Body

9. Coronary Arteries • Two major coronary arteries • arise from the aorta beyond the aortic valve. • Blood flows to the coronary arteries during diastole • Left main, LAD, Circumflex feeds most of Left side of the heart • Right feeds SA node, AV node, RA, RL

11. Collateral circulation is a network of tiny blood vessels, and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

12. Conduction System • SA node: (pacemaker) • initiates the impulse • travels thru atria to the AV node, located on the floor of the RA • Impulse is delayed at AV node, then transmitted to bundle of His

13. Conduction Continued

14. Cardiac Cycle • Contraction and relaxation of the heart: • Diastole: • Systole:

15. Video Mysterious Heart Volume 2 chapter 3

16. Cardiac Output • the volume of blood ejected by the heart each minute and is determined by stroke volume and the heart rate. • Normal stroke volume is 60-100 ml • Normal cardiac output is 4 to 8 L / min • (CO = HR X SV)

17. Factors affecting Stroke Volume • Preload: the amount of blood remaining in the ventricles at the end of diastole or the pressure generated at the end of diastole • Contractility: is the ability of the cardiac muscle fibers to shorten and produce a muscle contraction. (Inotropic, + or -) • Afterload: amount of pressure the Ventricle must overcome to eject blood volume out

18. Heart Rate • SA node : pacemaker of heart 60-100 bpm • AV node : 40 -60 bpm • Heart is innervated by sympathetic and parasympathetic nervous system • Sympathetic: speeds HR, and increases force of contraction • Parasympathetic: slows HR and force

19. Heart Tones • Murmur: Produced by turbulent sounds across valves • Rub: inflamed pericardium-best heard along left sternal border • S3 murmur: sounds like “Kentucky” • S4 murmur: sounds like “Mississippi” http://www.blaufuss.org/ http://www.med.ucla.edu/wilkes/Rubintro.htm

20. Health History

21. Present Illness • Fatigue • Edema • Palpitations • Pain • Aggravating and relieving factors

22. Past Medical History • HTN • renal disease • pulmonary disease • DM • CVA • rheumatic fever • streptococcal sore throat • scarlet fever • previous cardiac disease or conditions • currents meds and allergy

23. Family History: • CAD • HTN • DM

24. Review of systems • weight gain • fatigue • dyspnea • cough • orthopnea • palpitations • chest pain • fainting • concentrated urine • edema

25. Functional assessment • effects of illness on ADLs and rest patterns • smoker • diet • stress • coping

26. Physical Assessment • General: • VS: orthostatic bp in both arms, apical rate and rhythm, respiratory rate and effort • peripheral pulses: • Skin: color hair distribution, cap refill, temp • Thorax: heart sounds, lung sounds, sputum • Extremities: pulses, color, temp, edema

27. Age Related Changes • Heart less able to adapt to changing needs related to activity • Valves thicken and stiffen • # of pacemaker cells decrease • Nerve fibers decrease • Frequent dysrhythmias

28. Diagnostic Tests • EKG: rate, rhythm, ischemia (T-inverted), injury (ST segment elevation), arrhythmias, strain, infarction (q wave) • Echocardiogram: (TEE) sound wave test detects size of chambers, valve integrity, flow, wall motion, Cardiac Output

29. Diagnostic Tests Continued Biomarkers: Troponin will show elevation 3-6 hr after symptoms begin/injury peak in 12 hours stay in system 10-14 days <0.10 is negative 0.10-0.60 is intermediate and may indicate injury >0.60 is positive evidence of MI Myoglobin increases 1-4 hours after MI CPK-MB will show increase 4-6 hrs after MI peaks in 18-24 hours in system 2-3 days BNP can be elevated 48 hrs after MI which indicates heart failure

30. Diagnostic Tests Continued • CBC: anemia • CMP: screening K+, etc • PT, INR • PTT • Lipid profile: see next 2 slides

33. Diagnostic Tests Continued • ABG: assess acid/base levels • Pulse Oximetry: generally >92% • Holter monitoring: 24+ hr of EKG + events • Stress test: treadmill or pharmacological • Cardiac Catheterization: invasive, NPO 6-8h, consent. Visualizes chambers, valves, arteries, pressures, CO • Heart-CT scan: assesses CAD, MRI • Nuclear scans: assess heart muscle viability • EPS: NPO, consent, IV, assess electrical activity

35. CAD Video-mysterious heart volume 3 chapter 2

36. Etiology of CAD • CAD occurs when the intimal lining of the coronaries begin to plaque resulting in jagged edges and narrowed passageway for blood flow • Atherosclerosis results in impaired blood flow to the heart muscle

37. Risk Factors for CAD • Non-controllable- • Controllable-

38. s/s of CAD • Angina which results from a lack of 0xygen to the heart muscle • 4Es= • Weakness, diaphoresis, SOB • N/V

39. MI: Myocardial Infarction • Occlusion of a coronary artery resulting in necrosis of the heart muscle. • Risk factors: same as for CAD • Pathophysiology: AMI-over 4-6 hrs ischemia injury and infarction develop. Ischemia=lack of 02 to heart muscle, if not relieved=injury. After 20 min of ischemia=infarction • Main S/S: chest pain and accompanying S/S

40. Within 24 hours after infarction, healing begins, collateral circulation begins. • 10-14 days after MI=extension of MI may occur due to myocardial tissue vulnerability to stress • Complete scar formation and healing takes about 6 weeks Video- mysterious heart volume 1 chapter 2

41. Data Collection • Same as for CAD but will assess symptom of chest pain with accompanying s/s • May have EKG changes with or with-out ST-T wave changes or Q wave changes • Cardiac Bio-markers (Troponin, Myoglobin, CPK, CKMB) • May proceed with Echocardiogram to assess if wall motion sluggish • May go to cath lab

42. Angina or MI • Angina without MI} often relieved with rest and NTG • Angina with MI } may be relieved with rest, NTG, 02, MS, rescue angioplasty, etc. • Think MONA • Morphine • Oxygen • Nitroglycerin • Aspirin http://www.youtube.com/watch?v=4GlQmTlP2jE&feature=related

43. Treatment continued…video mysterious heart volume 3 chapter 3-7 • ASA: • MS: • Beta-blocker • ACE inhibitor:

44. Treatment continued • May need antiarrhythmic meds • like what??? • Stool softeners to reduce valsalva maneuver and prevent constipation r/t narcotic use and bed rest • Treat: HTN, DM other co-morbid illnesses • Cardiac Rehab to follow

45. Treatments • Low fat low cholesterol diet • Prescribed exercise program 5-7 days a week • Knows correct use of NTG for angina • Management of DM, HTN • Stop smoking • Medications to reduce work load or dilate

46. Low salt diet (<2000mg) does not include: • Soups: • Snacks:

47. Low fat <30% Low cholesterol <200mg • Lean meat: skinless • Dairy limited: egg beaters, skim milk • Olive oil, canola oil • Avoid: fried, fatty or heavily marbled meats, sausage, lunch meat, spareribs, frankfurters, salt pork, canned fish in oil, yolks, duck. Cream sauces, gravy, buttered vegetables, sweet rolls, other processed foods

48. Exercise • 5-7 X week is goal to include stretches with warm-up, progressive walking program, light weights, stretches with cool down. • Strengthens heart muscle, reduces BP, BS, weight, stress, tension, appetite, LDLs. • Increases HDLs, energy and self esteem and improves immune system

49. Principles of Exercise • Practice on regular basis • Know how to do own pulse • Strive for target heart rate • Stop if chest pain occurs • Complications: CHF & Dysrhythmias

50. Nursing interventions for MI • Comfort measures • Freq VS, cardiac monitoring, I&O, CMS checks, spacing activities • Heart & lung sounds, assess fluid volume status, IV responsibilities, note BP & Pulse prior to heart meds!! • Client education r/t diet, meds, pulse taking activity, elimination, reporting chest pain and correct use of nitro products for angina