Heart

Function of the Structures within the

Cardiovascular System
Heart
Pumping Action
Pumps blood to body and lungs
Receives blood from body and lungs
Influences blood pressure

Composition of the Heart

Valves
Atrioventricular (AV)
Tricuspid
Mitral (bicuspid)
Semilunar
Pulmonic valve
Aortic valve
Blood vessels of the heart
Coronary arteries, veins

Layers of the Heart

Pericardium
Four Chambers
Heart Valves
Arteries
Veins, Valves, & Skeletal Muscles
For blood to circulate
Arteries must be unobstructed, able to dilate and constrict as
necessary to regulate the blood flow.
Veins must be patent, their valves must function normally, and
surrounding muscles must contract so that venous blood is
continually being moved in the direction of the heart.
Circulation
To sustain life, the heart must pump blood throughout the body
on a regular, ongoing basis
Pulmonary Circulation – blood to the lungs
Coronary Blood Supply – blood to the heart
Systemic Circulation – blood to all parts of the body

Blood Supply to the Heart

Coronary Arteries
Left and Right
Collateral circulation
Coronary Veins

Conduction System
Cardiac Cycle
Contraction
Systole
Relaxation
Diastole
Heart Sounds
“lubdub”
Murmur
Rub is a high-pitched scratchy sound

Regulation of heart rate

Autonomic Nervous System
Sympathetic
Neurotransmitters excite the SA and AV nodes
Epinephrine
Dopamine
Increase heart rate

Factors that alter heart rate

Increase HR
 Exercise
Fever
Dehydration
Anxiety
Caffeine
Decrease HR
Rest
Hypothermia
Athleticconditioning
Vagal nerve stimulation

Assessment
History
Descriptionof symptoms
Past medical hx/family hx
Medication hx

Physical Examination
General appearance
Pain
Vital signs
T,P,R,BP

Cardiac rhythm
Heart sounds
Peripheral pulses

Physical Examination
Skin
Peripheral edema
Weight
Jugular veins

Lung sounds
Sputum
Mental status

Blood pressure
Pressure of the circulating blood against the walls of the arteries, the veins,
and the chambers of the heart.
Postural Blood Pressure (Orthostatic)
Position patient in supine and flat for 10 min. before taking the initial BP
and HR
Do not remove cuff but ensure placement if correct
Assess postural BP with patient sitting on the edge of the bed with feet
dangling
Then with patient standing at the side of the bed
Wait 1-3 minutes after each postural change before measuring
An increase of HR and decrease in systolic BP by 15mm Hg or 10mm Hg
in diastolic BP

Diagnostic Tests
Laboratory test
Blood chemistry
Serum enzymes and isoenzymes
Troponin, an enzyme in myocardial contractile tissue
Creatine kinase (CK)

Diagnostic Test
Echocardiography
Transesophageal echocardiography (TEE)

Electrocardiography
12-lead ECG
Holter monitor
Stress test

Diagnostic Test
Cardiac catherization
Observe for hematoma
Evaluate color, pulse and temp
Leg straight 2-6 hours post-procedure
Arteriography
Client and family teaching after cardiac
catherization
Activity
Dressing
Pulse sites
Force fluids
Vital signs

Doppler Studies
Cardiac Dysrhythmias

Dysrythmia/ Arryhthmia
Irregularity in the heart rhythm (heart beat)
Electrical conduction disorder results in:
Abnormally Slow heart rate
Abnormally Rapid heart rate
No heart rate at all.

Dysrythmia also referred to as Arrhythmia

Conduction System
ECG Electrocardiogram
Isoelectric Line
No electrical activity
Straight line produced
Waves upright or downward from isoelectric line

Heartbeat
P Wave
Impulse travels from SA through AV junction
Small,rounded, upright
Precedes the QRS complex
Atrial depolarization
PR Interval
Time it takes electrical impulse to be conducted through the atria and the AV node
 Measured from the P wave to beginning of the QRS complex
 Represent depolarization of heart from the atria through the AV node
(0.12-0.20 sec)

QRS Complex
Q wave – first negative or downward deflection; often not seen
R wave – first upward deflection
S- wave rest of the complex, the next downward deflection
QRS Complex – depolarization of the ventricles (both); conduction of
impulse through Bundle of His to purkinge fibers causing contraction of
ventricles
(0.04-0.12 sec)

T wave
- Represents heart reploarizing (relaxing), called refractory
period
 Rounded; shape of turtle shell
 (0.16 sec)

U Wave
If present indicates hypokalemia or reploarization abnormalities
Follows the T wave

ST Segment
Begins at the end of S waves and ends at the beginning of T wave
(0.12 sec)

Normal ECG Reflection

P wave
SA (atrial contraction)

QRS complex
Ventricular depolarization (contraction)

T wave
Ventricular repolarization (relax)
Interpretation of Cardiac Rhythm
5 – Step Plan
1. Regularity of rhythm….calipers, paper
2. Heart rate?
3. P wave
P-R interval
QRS complex

Heart Rate Determination

Determining Rate
3 seconds

Determining Rate
3 seconds

Determining
HEART RATE (Ventricular )
Easy and accurate method
Count the number of small boxes within an RR interval and divide 1500 by that
number
Less accurate, for irregular rhythm
Count the number or RR intervals in 6 seconds

RATE
Tachycardia
 HR greater than 100.

Bradycardia
HR less than 60.

Normal HR → 60-100
Normal Sinus Rhythm
Sinus
Rhythms
Look for a P wave
P wave → atrial contraction
Sinus Bradycardia
Sinus Tachycardia
Heart Disease
Coronary artery disease (CAD) is the most common type

Leading cause of death in U.S.

Coronary Artery Disease (CAD)
Is when the arteries that supply blood to the heart are narrowed and
hardened.
Due to the build up of plaque
Atherosclerosis

Cause of plaque build up?

Begins in childhood
Excessive fat in the blood, hyperlipidemia
High serum cholesterol or high levels of low-density lipoproteins
(LDL)
Diethigh in saturated fat cause increased blood cholesterol level
Genetics

Good vs. Bad

Lipoproteins
Low density (LDL)
Bad
Transfers fat to arteries
High density (HDL)
Good
Transfers fat to liver to be processed and used

Cholesterol Lab Values

Atherosclerosis
Risk Factors
Modifiable risk factors
Cholesterol levels
Cigarette smoking
Hypertension
Diabetes mellitus
Sedentary lifestyles
Obesity
Competitive, aggressive personality
High fat diet
Nonmodifiable risk factors
Age
Gender
Family history
Race

Prevention
Cigarette smoking should be discouraged.
Regular aerobic exercise that lasts 30–60 minutes on most days of the
week should be encouraged.
Diet high in veggies
High blood pressure should be identified and treated.
Obesity should be avoided or reduced.
Diabetes mellitus should be diagnosed and treated.

Foods to avoid
Red meat
Fried chicken
Whole milk
Egg yolks
Butter
Ice cream
Pastry

Atherosclerosis Summary
Narrow the arteries so that less blood can flow to the heart
muscle
Completely block the arteries and the flow of blood
Cause blood clots to form and block the arteries.

Potential Complication of CAD

Angina
Myocardial infarction
Heart attack

Myocardial Ischemia
Angina Pectoris
Pain in the chest

When the myocardial oxygen demand exceeds the supply, ischemia of the
heart muscle occurs, resulting in chest pain or angina
Symptoms
Pain
Dull or tightness under the sternum
May radiate down right arm
SOB
Palloror flushing
Profuse sweating
Apprehension

Treatment
The signs and symptoms of angina are often very similar to those
of MI.
Temporary
Often relieved by rest and medication
Nitroglycerin dilates the coronary arteries and increases the blood flow;
but does not affect MI pain.
Nursing Process
Assess chest pain and vital signs
Administer oxygen, drugs and encourage rest
Notify physician

Prevention
Eliminating modifiable risk factors
Avoid precipitating events
Physical exertion
Emotional excitement
Eating a heavy meal
Exposure to cold
Medications
Nitroglycerin
Statins
Antiplatelets

Medical and Surgical Management

Medical management
Drug therapy
Nitrates

Educate on lifestyle changes

Surgical management
PTCA (balloon angioplasty)
Coronary stent
CABG

Percutaneous Transluminal Coronary

Angioplasty
Nursing interventions for PTCA
Cleanses and remove hair from cath site
Withholds anticoagulants therapy before procedure
Monitors all vascular sites for bleeding (hematoma)
Assess all distal pulses
Monitor urine output
Reports chest pain, or abnormal vital signs

Coronary Stent
Coronary Artery Bypass Graft
(CABG)
Coronary artery revascularization utilizes another vein to bypass diseased
coronary artery

Heart Attack “a.k.a.” Myocardial Infarction

Atherosclerosis or
Embolus
Occludes major artery of blood flow
No oxygen to cells
Infarcted areas
Heart muscles die
Pain

Signs and Symptoms

Heavy pressure or squeezing
Pain, left arm and to the neck, jaw and teeth
Anxiety
Dyspnea
Weakness, faintness
Nausea
Pallor
Erratic behavior
Hypotension, shock
Cardiac rhythm changes
Vomiting
Fever
Diaphoresis

Pain with a myocardial infarction

Diagnostic Findings
Elevated serum cardiac markers
Troponin
Ck-MB (cardiac muscle-specific enzymes)
ECG changes
T-wave inversion

Medical Management
Increasetissue perfusion
Decrease workload of the heart
Promoting tissue oxygenation
Oxygen
Nitroglycerin
Relieving pain
Morphine
Preventing complications
Limit the size of the infarct
Thrombolytic therapy
PTCA
CABG

Thrombolytic Therapy
Dissolve clots in occluded artery, reopening the vessel and allowing
perfusion of the heart muscle.
3-6 hours of the onset of symptoms
st
Most effective in 1 1hour
Excluded
Internalbleeding
Aneurysm
Recent head trauma
Hx of hemorrhagic stroke
Surgery within the past 10 days

Nursing Intervention
Administer oxygen
Administer medications
IV Morphine
Heparin
Antiplatelets
Stool softeners
Bed rest

Teaching
Treatment regimen
Cardiac rehab
Medications
Lifestyle changes
Dietary restrictions
Sexual activity
Warning symptoms

Nursing Process for MI

Assessment
Client’s description of pain
 Vitalsigns
Cardiac rhythm

Nursing Process for MI

Nursing Diagnosis
Acute pain related to diminished myocardial oxygenation
Ineffective tissue perfusion (cardiovascular) related to
____________________
Anxiety or Fear

Nursing Process for MI

Interventions
Administer prescribed nitroglycerin
Administer morphine
Administer oxygen
Pain will be within client’s identified comfort level within
30minutes
Occlusive Disorders of Peripheral
Blood Vessels
Peripheral Vascular Disease
“PVD”
What is peripheral vascular disease?
Peripheral vascular disease, or PVD, is a condition in which the
blood vessels that carry blood to the arms or legs become narrowed
or clogged.
Arterial
Venous

Symptoms of PVD
Intermittent claudication- pain with exercises, particularly
walking, causes excruciating pain in limb that disappears at rest.
Tingling and numbness – extremity becomes numb, or the feeling
of a persistent tingling sensation, caused by poor circulation
Symptoms of PVD
Coldness and difference in size- extremities feel cold to touch,
one leg may be colder and larger than the other.
Lack of tissue growth- skin becomes paper thin, shiny, and easily
subject to breakdown
Venous stasis ulcers- breakdown from inflamed skin causing
fluid to ooze causing skin to be impaired

Arteriosclerosis
Goals for peripheral arterial disease
Increased arterial blood supply to the extremities
Promotion of vasodilation
Prevention of vascular compression
Relief of pain
Maintaining tissue integrity

Interventions
Positioning the part below the level of heart
Reclining position
Walking
Not with pain
Promoting vasodilation
Warmth, avoid cold temperatures
Warm clothes, warm drink
Pt should test temp first

Nursing care for PVD

Protect the client’s feet and legs from undue pressure of linens
Take great care in trimming toenails
Be sure to dry carefully between the toes after washing them
Be very careful about application of heat. Use extra clothing
rather external heat
Use warm baths to increase circulation

Postoperative Treatment
Pulses
Color and temperature
Capillaryrefill
Sensory and motor function

Allow no leg crossing, LOC, UO,VS, Bleeding, elevate extremity, monitor

incision site for infection

Notify surgeon of any changes immediately

Raynaud’s Disease
Constriction
Briefspasms
Females that get upset, cold, or smokes
Fingers turn blue, then white, then red
Painful and cause ulceration
Avoid cause, use warmth.

Peripheral thrombosis (arterial embolism)

Embolus lodges in a blood vessel causing blockage
Severe pain at site
Distal portion pale, cold, numb, and no pulse
Without circulation gangrene occurs
Amputation
Endarterectomy
Embolectomy

Peripheral thrombosis (arterial embolism)

Embolus lodges in a blood vessel causing blockage
Severe pain at site
Distal portion pale, cold, numb, and no pulse
Without circulation gangrene occurs
Amputation
Endarterectomy
Embolectomy

Venous Disorders
Venous insufficiency
Varicose veins
Venous Insufficiency
Blood pools in the lower extremity
Fluid leaves the blood vessel
Causing edema and the skin to become shiny and hard
Unoxygenated cells die causing release of inflammatory
chemicals
Skin becomes red and hot, tissue appears dark brown, deep
purple, or black
Chronic Venous Insufficiency
Results from obstruction of venous valves in legs or reflux of
blood back through valves
Venous ulceration is serious complication
Pharmacological therapy is antibiotics for infections

Venous stasis ulcer

Medical Management
Promote wound healing and preventing infection
Diet
Protein intake
Albumin is lost through ulcers
Vitamin A& C, zinc needed to promote tissue healing
Debridement of necrotic tissue
Wet-to-dry dressing
Enzyme ointments
Surgical debridement
Unna’s paste boot
Disorders of blood vessel walls
Varicose veins results from weakening of the valves of the veins so that
blood pools in the legs.
The congestion stretches the veins and over time they cannot recoil and
remain distended.
Prolonged standing
Elevate the legs for a few minutes throughout day
Avoid constricted clothing
Stripping and ligation of surgical therapy
Early ambulation is important after surgery.

Varicose Veins
Blood Pressure
Force of blood against the walls of the arteries
Blood Pressure Readings Categories
What is hypertension?
High Blood Pressure
Remains elevated overtime
 Systolic blood pressure greater than 140mm Hg
Diastolic blood pressure greater than 90 mm Hg
Based on an average of two or more consecutive measurements

Hypertension
Primary
No known cause

White coat
Anxiety
Secondary
Identified cause
Narrowing of renal arteries
Pregnancy
medications

Essential (Primary) Hypertension

Causes of hypertension
Sympathetic nervous system activatio
Genetic factors
Sedentary lifestyle
Increased sodium intake
Excessive alcohol intake
Age influence

Prognosis
With prolonged untreated essential hypertension, the elastic
tissue in the arterioles is replaced by fibrous tissue.
This process leads to decreased tissue perfusion, especially in the
target organs-heart, kidney, and brain-resulting in deterioration of
major organs.
Secondary Hypertension
Identifiable medical diagnosis
Renal vascular disease
 Pregnancy-induced
Prognosis
Subsides when primary disease process is treated or corrected
Risk Factors
Nonmodifiable Risk Factors
Age
Gender
Race
Family history

Modifiable Risk Factors

Smoking
Obesity
High-sodium diet
Elevated serum cholesterol
Oral contraceptives
Alcohol
Emotional stress
Sedentary lifestyle

Symptoms “The Silent Killer”

Fatigue
Confusion
Nausea or upset stomach
Vision changes or problems
Excessive sweating
Paleness or redness of skin
Nosebleeds

Anxiety or nervousness
Palpitations
Ringing or buzzing in ears
Impotence
Headache
Dizziness

HTN
Heart disease
Stroke
Heart failure
Kidney disease
Blindness

Medical Management
Drugtherapy
Nonpharmacological therapy
Lose excess weight
Reduce saturated fat
Limit alcohol intake
Exercise regularly
Reduce sodium intake
Stop smoking

Low Na+ Diet

Buy fresh, plain frozen, or canned “no salt added” vegetables
Fresh poultry, fish, and lean meat
No canned or processed types
Herbs, spices, and salt-free seasoning blends in cooking
Cut back on frozen dinners, pizza, packaged mixes, canned soups or
broths, and salad dressings
Rinse canned foods
Low or reduced sodium or no salt-added

Inflammatory Disorders of the

Peripheral Blood Vessels
Disorders
Thrombophlebitis
Deep vein thrombosis (DVT)
Buerger’s disease

Thrombophlebitis
Deep vein thrombosis, DVT
Contributing factors
Immobility (venous stasis of blood)
Trauma
Sepsis
Clotting problems
Cancer
Obesity
 Oral hormone replacement
Dehydration

Assessment findings
Treatment is aimed at Prevention
Early
movement
Mechanical prophylaxes
Compression elastic stockings
Sequentialcompression devices (SCD)
Pneumatic compression devices
Pharmacologic prophylaxis
Aspirin
Coumadin
Heparin
LMWH- Lovenox

Treatment is aimed at Prevention

Early
movement
Mechanical prophylaxes
Compression elastic stockings
Sequential compression devices (SCD)
Pneumatic compression devices
Pharmacologic prophylaxis
Aspirin
Coumadin
Heparin
LMWH- Lovenox

Treatment
Complete bed rest
Anticoagulant therapy
Warm wet packs
Thrombectomy
Vena cava filter (Greenfield filter)

Nursing Process for Thrombophlebitis

Assessment
Hx of blood clots or past orthopedic surgery
High risk lifestyles or medical treatment
Assess for Homan’s sign, inspect extremities
Diagnosis
 Pain related to venous inflammation
Ineffective Tissue Perfusion related to localized swelling secondary to the
inflammatory response and impaired venous circulation
Nursing Process for Thrombophlebitis
Planning
Prevention for bedridden
Promote activity and exercise
Ankle-pumping exercises
TED hose (elastic stocking)
 venous compression devices

Prevention for recurrences

Avoid prolonged sitting, crossing legs
Elevate legs, active movement, wear hose, and drinking fluids liberally
Long term anticoagulant therapy
Watch for signs –nosebleeds, bleeding easily

Nursing Process for Thrombophlebitis

Interventions
Administer prescribed non-narcotic analgesics and anti-inflammatory
agents.
Support and handle extremity gently
Elevate the affected extremity, do not bend at knees
Apply warm, moist compresses

Potential complications (PC) of

Thrombophlebitis
Pulmonary embolus
Maintain bed rest
Administer prescribed anticoagulant
Ted hose
Bleeding
Monitor lab values (PTT, PT, INR)
Keep antidotes for overdose of anticoagulants
Monitor for signs of bleeding (skin, gums, stools)
Apply direct pressure if bleeding occurs

Anticoagulants
Heparin & Coumadin
Preventsthe formation of a blood clot
Does not effect existing thrombus
Body will dissolve over time
Anticoagulants
Heparin
Low-molecular weight heparin
Lovenox
Fragmin
Coumadin
Aspirin (antiplatelet)

Lab values
Heparin
Activated partial thromboplastin time (APTT or PTT)
LMWH
No effect on lab values
Coumadin
Prothrombin time and international normalized ration
(PT & INR)

Thrombolytic Therapy
May be used to dissolve the thrombus
Streptokinase
Urokinase
TPA tissue plasminogen activator
High risk for bleeding
Used only in emergency situation
Used only in good candidates

Monitoring
Adverse drug reaction
Bleeding
Inspect urine & stool for any GI bleeding
Skin for bruising
 Avoid skin cuts

Reverse Effects
Heparin
Protamine sulfate
Coumadin
 Vitamin K
Avoid foods high for therapeutic
dark leafy vegetables
Frozen fresh plasma
Buerger’s Disease (Thromboangiitis Obliterans)
Inflammatory lesions along small arteries and veins
Arteries prone to spasm
More common in men
Smoking aggravates the condition
Causes gangrene

Nursing Process for Buerger’s Disease

Assessment
Cold feet with numbness, burning and tingling
Intermittent claudication, leg cramps after exercise
Pain at rest
Skin mottled purplish-red and appears thin and shiny
Black gangrenous areas on toes and heels

Nursing Process for Buerger’s Disease

Teaching topics
Smoking cessation
Performing prescribed exercises
Avoid caffeine, tobacco products, and OTC drugs
Prevent trauma to extremities
Avoid prolonged exposure to the cold

Nursing Process for Buerger’s Disease

Medical management/nursing interventions
Tobacco is restricted
Buerger-Allen exercises
Analgesics
Wet-to-dry dressings

Results in Gangrene