1|MEDICAL-SURGICAL NURSING I
CARE OF CLIENTS WITH PROBLEMS IN
OXYGENATION
A. CARDIOVASCUCULAR SYSTEM
a. Basic Anatomy and Physiology
HEART
 Hollow, muscular organ
 Occupies mediastinum, rests on diaphragm
 300 g
 Pumps blood to tissues, oxygen & nutrient
supply
 3 layers:
(1) endocardium – inner layer, endothelial
tissue, lines inside of heart and valves
(2) myocardium – middle, muscle fibers,
pumping action
(3) epicardium – outer layer, thin fibrous sac,
composed of 2 layers
i. visceral epicardium – adheres to the
epicardium
ii. parietal epicardium – tough, fibrous
tissue, attaches to great vessels,
diaphragm, sternum, vertebral column;
supports heart in mediastinum
 pericardial space – lubrication, reduce
friction
HEART CHAMBERS
 Atria + ventricles
 Diastole – relaxation phase; 4 chambers relax
simultaneously; ventricular filling
 Systole – contraction phase; atrial +
ventricular contraction; not simultaneous
(atrial contraction first, followed by
ventricular) – to allow complete ventricular
filling prior to ejection
 Right side – receives deoxygenated blood via
pulmonary artery (only artery that carries
deoxygenated blood) for oxygenation
**pulmonary circulation
o Right atrium – receives venous blood
from superior + inferior vena cava +
coronary sinus
 Left side – distributes oxygenated blood via
aorta **systemic circulation
o Left atrium – receives oxygenated
blood via 4 pulmonary veins
 Ventricular walls are much thicker than atrial
walls bec they must overcome resistance to
blood flow from pulmonary and systemic
circulation respectively
 Left ventricle -2 to 3x more muscular than
right (must overcome high aortic and arterial
pressure)
HEART VALVES
 Permit blood to flow in one direction; prevent
backflow
 Atrioventricular – tricuspid + bicuspid
(mitral)
o During diastole – open
o systole – close; papillary muscles +
chordae tendineae maintain closure
 Semilunar – pulmonic + aortic
o Diastole – closed
o Systole – open as blood is ejected to
pulmonary artery & aorta respectively
CORONARY ARTERIES
 Supply arterial blood
 Originate from aorta
 Heart extracts 70-80% of oxygen delivered
(others – 25%)
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 Perfused during diastole
 ↑ HR = ↓ diastolic time = myocardial
ischemia during tachy
 left coronary artery – 3 branches (left main
coronary artery: left anterior descending
artery, circumflex artery
 right coronary artery – supplies right side;
posterior descending artery
 coronary veins – venous blood return to heart
through coronary sinus
FUNCTION OF THE HEART
Cardiac Electrophysiology
 Cardiac conduction system – generates +
transmits electrical impulses that stimulate
contraction
 Atria first and then ventricles
 Nodal cells + purkinje cells – electrical cells
 Automaticity – initiate electrical impulse
 Excitability – respond
 Conductivity – transmit
 SA node & AV node – nodal cells
1. SA Node – primary pacemaker; 60 – 100
bpm
* Internodal pathways
2. AV node – delays electrical impulse to
allow for ventricular filling; 40c – 60 bpm
3. Bundle of His – right + left bundle branch
 Left bundle branch – left anterior + left
posterior bundle branch
4. Purkinje Fibers – ventricular contraction;
20 – 40 bpm
CARDIAC HEMODYNAMICS
 Cardiac cycle – diastole, atrial systole,
ventricular systole
o Hemodynamic Monitoring – measure
chamber pressure
 Cardiac Output – total amt of blood ejected
by one of the ventricles in L/min; 4-8 L/min;
HR x SV
 Stroke volume – amt of blood ejected by one
of the ventricles per heartbeat/ systole; 60-130
mL
Effects Of Hr On Co
 Changes in HR d/t inhibition or stimulation of
SA node (parasympa & sympa of ANS)
 Parasympathetic impulses – travel through
vagus nerve, slow HR
 Sympathetic impulses – increase HR;
innervation of beta-1 receptor sites in SA
node
o Catecholamines & excess thyroid hormone
 Baroreceptors – sensitive to changes in BP
o Hypertension – baroreceptors increase rate
of discharge = initiates parasympathetic
activity; inhibits sympa = ↓ HR
o Hypotension – less baroreceptor
stimulation = ↓ parasympa activity = ↑
sympa response
Effects Of Stroke Volume On Co
 Preload – degree of stretch of ventricular
cardiac muscle fibers @ the end of diastole
o Amt of blood returning to the heart
o ↑ vol of blood returning to heart = ↑
muscle fiber stretch ( ↑ preload) = ↑
contraction = ↑ SV
o Diuresis, venodilating agents (nitrates),
excessive loss of blood, dehydration –
reduce preload
o To increase preload – control loss of blood
or body fluids, replace fluids
 Frank – Starling Law - ↑ initial length of
stretch = ↑ force of contraction
 Afterload – resistance to ejection of blood
from ventricle; resistance that the ventricles
must overcome to eject blood
o Systemic vascular resistance
o Pulmonary vascular resistance
 Contractility – force of contraction
o Enhanced by: catecholamines, sympathetic
activity, meds (Digoxin, Dopamine,
Dobutamine)
o Depressed by: hypoxemia, acidosis, meds
(beta-blockers such as metropolol
[Lopressor])
 Ejection fraction – percentage of end-diastolic
blood volume that is ejected with each
heartbeat
o 55% - 65%
Gerontologic Considerations
 Hypertrophy - ↑ size, heart walls thicken, ↓
vol of blood that chambers can hold, ↓
strength of contraction
 Stiffening of valves – backflow creates heart
murmurs
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Gender Considerations - Type A personality - compensatory mechanisms (peripheral

 Women – smaller heart, narrower coronary - Contraceptive pills vasoconstriction, tachycardia)
arteries; cardiac catheterization & angioplasty
more difficult Health History General Appearance
o Develop CAD 10 yrs later than men d/t i. Common Symptoms  LOC & mental status (changes may indicate
estrogen (cardioprotective effects)  Chest pain or discomfort (Angina pectoris, inadequate perfusion)
o Major effects of estrogen: (1) an increase ACS, dysrhythmias)  Signs of distress (pain/discomfort, dyspnea,
in high-density lipoprotein (HDL) that  Upper body pain/ discomfort (arms, back, anxiety)
transports cholesterol out of arteries; (2) a neck, jaw, stomach)  Size of px (normal, overweight, underweight,
reduction in low-density lipoprotein (LDL)  Dyspnea (ACS, cardiogenic shock, HF, cachectic)
that deposits cholesterol in the artery; and valvular heart disease)  Weight & height, BMI
(3) dilatation of the blood vessels, which  Edema, weight gain, abdominal distention
enhance blood flow to the heart.  Palpitations Assessment of Skin and Extremities
 Unusual fatigue (vital exhaustion)  Skin color, temperature, texture
ASSESSMENT OF THE  Dizziness, syncope, changes in LOC o Acute obstruction of arterial blood flow: 6
CARDIOVASCULAR SYSTEM P’s – pain, pallor, pulselessness,
b. Cardiovascular Risk Factors c. Principles And Techniques Of Physical paresthesia, poikilothermia, paralysis
Non Modifiable Risk Factor Examination And Deviation From o Observe catheter access sites
- Age Normal o Peripheral edema (feet, ankles, legs);
- Gender Physical Assessment pitting edema
- Race Nurse evaluates:  0 = absent
- Heredity - heart as a pump (reduced pulse pressure,  1+ = 2mm (slight); barely perceptible
Modifiable Risk Factor displaced PMI from fifth intercostal space  2+ = 4mm; rebounds in a few seconds
- Stress midclavicular line, gallop sounds,  3+ = 6mm; 10-20 secs
- Diet murmurs);  4+ = 8mm >30 sec
- Exercise - atrial and ventricular filling volumes & o Prolonged capillary refill time – inadequate
- Sedentary lifestyle pressures (elevated jugular venous arterial perfusion to extremities; compress
- Cigarette smoking distension, peripheral edema, ascites, nail bed; normal is < 2 secs
- Alcohol crackles, postural changes in BP); o Clubbing – chronic hgb desaturation;
- Hypertension - CO (reduced pulse pressure, hypotension, o Hair loss, brittle nails, dry/scaling skin,
- Hyperlipidemia tachycardia, reduced urine output, atrophy, skin color change, ulcerations
- DM lethargy, or disorientation);  Blood pressure
- Obesity
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o Normal: 120/80
o Hypertension: 140/90 and up
o Pulse Pressure
 Systolic – Diastolic
 30 to 40 mmHg
 How well patient maintains CO
 ↑ PP = ↑ SV (anxiety, exercise,
bradycardia), fever, atherosclerosis,
aging, hypertension
 ↓ PP = ↓ SV & ejection velocity
( shock, HF, hypovolemia, mitral
regurgitation, mitral or aortic stenosis
o Orthostatic BP changes
 Normal: lying to standing = (1) HR ↑ of
5 to 20 bpm; (2) unchanged or slight ↓
in systolic of up to 10 mmHg (3) slight
↑ in diastolic of 5 mmHg
 Orthostatic hypotension = ↓ at least 20
mmHg (systolic); 10 mmHg in diastolic
BP within 3 mins; dizziness,
lightheadedness, syncope
 Arterial Pulses
o Pulse Rate – 60 to 100; 50 bpm in healthy
athletic young adults
 Reassess pulse near end of PE (px is
more relaxed)
o Pulse rhythm – normally regular
 Sinus arrhythmia – increase during
inhalation; decrease during exhalation
(children, young adults)
 Auscultate apical pulse for 1 min while
simultaneously palpating radial pulse
 Arrhythmias – pulse deficit (difference
bet apical and radial pulse
o Pulse amplitude – absent, diminished,,
normal, bounding
 0: not palpable/ absent
 +1: diminished – weak, thready
 +2: normal – cannot be obliterated
 +3: moderately increased – easy to
palpate, full pulse
 +4: markedly increased – bounding,
may be abnormal
o Pulse contour
 Aortic valve stenosis – narrowed valve,
reduced amount of blood in aorta; PP
narrow, feeble pulse
 Aortic insufficiency – aortic valve does
not close completely; blood flows back
into left ventricle
 Palpate over carotid artery
 Jugular Venous Pulsations
o Right sided heart function – observe
jugular veins of neck; reflects CVP
o CVP – pressure in right atria or right
ventricle
o Euvolemia (normal) – JV normally visible
in supine position, head of bed elevated to
30 degrees
o Obvious distention @ 45 to 90 degrees =
abnormal increase in CVP
o Observed in right sided HF
Heart Inspection and Palpation
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