Handouts in NGCM103 Oxygenation

Note: Please still refer to your MS book

Cardiovascular System
Anatomy and Physiology of the CV system
o Heart
 Muscular pump that propels blood into the arterial system and receives blood from the
venous system
Coronary Circulation
o Coronary Arteries
 Branch off at the base of the aorta and supply blood to the myocardium and the
conduction system:
Two main coronary arteries: right and left
o Coronary Veins:
 Return blood from the myocardium back to the right atrium via the coronary sinus
Functions
 Circulation of blood
 Delivery of oxygen and other nutrients to the tissues of the body and removal of Carbon
dioxide and other products of cellular metabolism
Heart
 Pericardium
 Epicardium
 Myocardium
 Endocardium

Conduction System
o SA node
 pacemaker of the heart
 Initiates the cardiac impulse
 spreads across the atria and into AV node
o AV node
 Delays the impulse from the atria while the ventricles fill
o Bundle of His
 Arises from the AV node and conducts impulse to the bundle branch system
o Right bundle branch
 Divided into anterior, lateral and posterior
 Transmits impulses down the right side of the intraventricular septum toward the right
ventricular myocardium
o Left bundle branch: divided into anterior and posterior
 Anterior:
 Transmits impulses to the anterior endocardial surface of the left ventricle
 Posterior
 Portion transmits impulses over the posterior and inferior endocardial
surfaces of the left ventricle.
o Purkinje fibers
 Transmit impulses to the ventricles and provide for depolarization after ventricular
contraction

CARDIAC DYSRHYTHMIAS
Abnormal electrical conduction or automaticity causing changes in heart rate and rhythm.
May take a variety of forms

Causes:
Congenital
Myocardial Ischemia
MI
Organic heart disease
Drug effects and toxicity
Conductive tissue degeneration
Electrolyte Imbalance
Acid-base imbalances
Result from a disturbance in excitability, automaticity, or conductivity
Heart rate and rhythm are altered, reducing cardiac output

Diagnostic Findings
ECG changes in heart rate, rhythm
Blood chemistry:
Electrolyte imbalance

SINUS TACHYCARDIA
A heart rate of over 100 bpm originating in the SA node

Causes:
Fever
Apprehension
Physical activity
Anemia
Hyperthyroidism
drugs(epinephrine, theophylline)
Myocardial Ischemia
Caffeine

Assessment Findings:
100-160bpm
Rhythm: regular
P wave: precedes QRS complex with normal contour
P-R interval: normal (0.08 seconds)
QRS complex: normal (0.06 seconds)
Treatment:
Correction of underlying cause
Elimination of stimulants
Sedatives
Propanolol(Inderal) as ordered.

SINUS BRADYCARDIA
A slowed heart rate initiated by SA node

Causes:
Excessive vagal or decreased sympathetic tone
MI
Intracranial tumors
Meningitis
Myxedema
Cardiac Fibrosis
Normal variation in well-trained athletes

Assessment Findings
Rate: less than 60bpm
Rhythm: regular
P Wave: precedes each QRS with a normal contour
P-R interval: normal
QRS complex: normal

Treatment
Usually not needed if CO is inadequate
Atropine, Isoproterenol (Isuprel) as ordered
If drugs are not effective,
A pacemaker may need to be inserted

ATRIAL FIBRILLATION
An arrhythmia in which ectopic foci cause rapid, irregular contractions of the heart.
Commonly seen in clients with:
rheumatic mitral stenosis
Thyrotoxicosis
Hypertensive heart disease
Pericarditis
CHD

Assessment Findings:
Rate:
Atrial: 350-600bpm
Ventricular: Varies between 100-160bpm
Rhythm: Atrial and Ventricular regularly irregular
P wave: no definite P wave: rapid undulations called fibrillatory (f) waves
P-R interval: not measurable
QRS complex: generally normal

Treatment:
Digitalis Preparations
Propanolol
Verapamil in conjunction with digitalis
Direct-current Cardioversion

PREMATURE VENTRICULAR CONTRACTIONS

Irritable impulses originate in the ventricles.

Causes:
Electrolye imbalance(Hypokalemia)
Digitalis Drug therapy
Myocardial disease
Stimulants (Caffeine, Epinephrine, Isoproterenol)
Hypoxia
CHF
Assessment Findings
Rate: varies according to number of PVCs
Rhythm; irregular because of PVCs
P wave: normal: however, often lot in QRS complex
P-R interval: often not measurable
QRS complex: wide and distorted in shape, greater than 0.1 seconds

Treatment
IV push of Lidocaine (50-100 mg) followed by IV drip of Lidocaine at rate of 1-4 mg/minute
Decreases conduction rate and force of contraction
Procainamide (Pronestyl), Quinidine
antiarrhythmic
Treatment of underlying cause

VENTRICULAR TACHYCARDIA
A run of three or more consecutive PVCs
Occurs from repetitive firing of an ectopic focus in the ventricles

Causes:
Acute MI
CAD
Digitalis intoxication
hypokalemia

Assessment Findings
Rate
Atrial : 60-100bpm
Ventricular: 110-50bpm
Rhythm
Atrial (regular), ventricular (occasionally regular)
P wave: often lost in QRS complex
P-R interval: usually not measurable
QRS complex: greater than 0.1 seconds, wide

Treatment
IV push of Lidocaine (50-100 mg) then IV drip of Lidocaine (1-4 mg/minute)
Procainamide via IV infusion of -6 mg/minute
antiarrhythmic 
Direct-current cardioversion
Bretylium, Propanolol(Inderal)
antiarrhythmic agent

CORONARY ARTERY DISEASE

Refers to a variety of pathologic conditions
cause narrowing or obstruction of the coronary arteries resulting in decreased blood supply to the
myocardium.
Atherosclerosis
Deposits of cholesterol and lipids within the walls of the artery
Major causative factor
Occurs most often between ages 30-50
Men are affected more
Nonwhites have higher mortality rates

Risk Factors
Family history
Elevated serum lipoprotein
Cigarette smoking
DM
Hypertension
Obesity
Sedentary and/or stressful life-style
Elevated serum uric acid levels
ANGINA PECTORIS
Transient, paroxysmal chest pain produced by insufficient blood flow to the myocardium
Resulting in myocardial ischemia

Risk Factors
CAD
Atherosclerosis
Hypertension
DM
TAO
Severe Anemia
Aortic Insufficiency

Precipitating Factors
Physical exertion
Consumption of a heavy meal
Extremely cold weather
Strong emotions
Cigarette smoking
Sexual activity

Assessment Findings
Pain: substernal with possible radiation to the neck, jaw, back and arms
relieved by rest
Palpitations, tachycardia
dyspnea
Diaphoresis
Increased serum lipid levels

Diagnostic Tests
ECG:
May reveal ST segment depression and T wave inversion during chest pain
Stress test
May reveal an abnormal ECG during exercise

Medical Management
During therapy:
Nitrates
treat and prevent angina
Beta-Adrenergic locking agents
Calcium-blocking agents
Lipid-reducing drugs if cholesterol elevated
Modification of diet and other risk factors

Surgical Management
Coronary Artery Bypass Surgery
Surgery of choice for CAD
New supply of blood brought to the diseased/occluded coronary artery by bypassing the obstruction
with a graft that is attached to the aorta proximally and to the coronary artery distally.

Nursing Intervention
Administer oxygen as ordered
Give prompt pain relief with nitrates or narcotic analgesics as ordered
Monitor V/S, status of cardiopulmonary function
Monitor ECG
Place in Semi-high Fowler’s position
Provide emotional support
Provide client teaching and discharge planning:
Proper use of nitrates
Nitroglycerin tablets(sublingual)

Nitroglycerin Health Teaching

Allow tablet to dissolve
 Relax for 15 minutes after taking tablet
To prevent dizziness
If no relief with 1 tablet, take additional tablets at 5 minute interval, but no more than 3 tablets
within a 15 minute interval period
Know that transient headache is a frequent side effect
Keep bottle tightly capped and prevent exposure to air, light and heat
Ensure tablets are within reach at all times.
Check shelf-life, expiration date of tablets

Nitroglycerin ointment
Rotate sites to prevent inflammation
Remove previously applied ointment
Avoid massaging/rubbing as this increases absorption and interferes with the drug’s sustained
action
Ways to minimize precipitating events(Angina)
Reduce stress and anxiety- relaxation techniques
Avoid overexertion and smoking
Maintain low-cholesterol, low saturated fat diet and eat small frequent meals
Avoid extremes of temperature
Dress warmly in cold weather
Gradual increase in activities and exercise
Participate in regular exercise program
Space exercise periods and allow rest periods

ACUTE CORONARY SYNDROME

complication of CAD due to lack of oxygen to the myocardium.

Manifestations:
unstable angina
non ST-segment elevation infarction
ST-segment elevation infarction.
May manifest as angina pectoris or MI
LABORATORY/DIAGNOSTIC TESTS
A. Blood chemistry and electrolyte analysis
1. Cardiac enzymes: will be elevated with myocardiac infarction
a. Creatine phosphokinase(CPK) 50-35 mU/ml
b. CPK-MB o%
c. Lactic acid dehydrogenase (LDH) 100-225 mU/ml
i. LDH1 20%-35%
ii. LDH2 25%-40%
d. Aspartate aminotransferase(AST), also called serum glutamic oxaacetate(SGOT) 7-
40 U/ml
2. Electrolytes
a. Sodium(Na): 135-145 mEq/l; reflects relative fluid balance, hyponatremia indicates
fluid excess and hypernatremia indicates fluid deficit
b. Potassium (K):3.5-5 mEq/: increased and decreased levels can cause dysrhythmias
c. Magnesium(Mg): 1.3-2.1 mEq/: decreased levels can cause dysrhythmias
d. Calcium(Ca):4.5-5.3 mEq/, 9-11 mg/d: cacium necessary for blood clotting and
neuromuscular activity, decreased levels cause tetany, increased levels cause
muscle atony, increased and decreased levels can cause dysrhythmias.
3. Serum lipids
a. Total cholesterol: 150-200 mg/dl: elevated levels predispose to atherosclerotic
heart disease
b. High density lipids (HDL)30-85 mg/dl; low levels predispose to cardiovascular
disease
c. Low density lipids(LDL): 50-140 mg/dl: high levels predispose to atherosclerotic
plaque formation
d. Trigycerides: 10-150 mg/dl: high levels increase risk of atheroclerotic heart disease
4. Hematologic Studies
a. Coagulation time: 5-15 min: increased levels indicate bleeding tendency, used to
monitor heparin therapy
b. Prothrombin time(PT) 9.5-12 sec: INR 1.0, increased levels indicate bleeding
tendency, used to monitor warfarin therapy.
c. ESR <20 mm/hr; increased level indicate inflammatory process.
5. Urine Studies: routine urinalysis
6. Eectrocardiogram(ECG or EKG)
a. Noninvasive test that produces a graphic record of the electrical activity of the
heart. In addition to determining cardiac rhythm, pattern variations may revea
pathologic processes (MI and ischemia, electrolyte and acid-bae imbalance,
chamber enlargement, block of the right or left bundle branch.
b. Portabe recorder(Holtor monitor) provides