CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM
 Provide oxygen in every tissue in the body which is EPICARDIUM
essential in performing its function  exterior layer of the heart
 Consists of:  coronary arteries
o Heart MYOCARDIUM
o Blood Vessel  middle layer
o Blood  thickest layer
 is made up of muscle fibers and is responsible for the
HEART pumping action
 heart is a hollow, muscular organ located in the center of ENDOCARDIUM
the thorax, where it occupies the space between the lungs  lines the inner surfaces of the heart chambers, including
(mediastinum) and rests on the diaphragm the heart valves
 Location: Mediastinum
 Description: HEART CHAMBER
o Inverted Cone  The pumping action of the heart is accomplished by the
o Size of a fist rhythmic relaxation and contraction of the muscular walls
of its two top chambers (atria) and two bottom chambers
(ventricles)
 Right Side: workload is light: pulmonary circulation
o right atrium and right ventricle, distributes venous
blood (deoxygenated blood) to the lungs via the
pulmonary artery (pulmonary circulation) for
oxygenation.
 Left Side: high pressure system; systemic circulation
o left atrium and left ventricle, distributes oxygenated
blood to the remainder of the body via the aorta
(systemic circulation).

CARDIAC VALVES
 prevents backflow of blood
 The four valves in the heart permit blood to flow in only
one direction.
 There are two types of valves: atrioventricular (AV) and
semilunar.

HEART SOUNDS
 S1: Tricuspid & Mitral Close: “LUBB”
 S2: Aortic & Pulmonic Close: “DUBB”
GALLOP SOUND
 Abnormal in adults; Normal in children
o S3: Ventricular Gallop
HEART WALL  Occur after S2
 Congestive Heart Failure (CHF)
PERICARDIUM
o S4: Atrial Gallop
 The heart is encased in a thin, fibrous sac called the
 Occur just before S1
pericardium
 Coronary Artery Disease (CAD)
 Two layers:
o Visceral: Adhering to the epicardium
STETHOSCOPE
o Parietal: Enveloping the visceral pericardium; tough
fibrous tissue that attaches to the great vessels,  Diaphragm: High sound
diaphragm, sternum, and vertebral column and  Bell: Low sound
supports the heart in the mediastinum.
 Pericardial Space: 5 AREAS OF LISTENING
o The space between the two layers  AORTIC
o filled with 10-50mL of fluid; Reduces friction o Right 2nd ICS
o Pericardial Effusion: excess fluid: results in DOB  PULMONIC
o Left 2nd ICS
 ERB’S POINT

A.Y. 2023-2024 | BSN 3-B 1

 o Left 3rd ICS  Fastest conduction
o Murmur sounds  the terminal point in the conduction system
 TRICUSPID SOUND  rapidly conduct impulses throughout the thick
o Lower left 4th ICS walls of the ventricles
 MITRAL  Three physiologic characteristics of two types of
o Left 5th ICS MCL specialized electrical cells, the nodal cells and the Purkinje
o Apex of the heart cells, provide this synchronization:
o Automaticity: ability to initiate an electrical impulse
o Loudest sound of the heart is heard
o Excitability: ability to respond to an electrical impulse
o Point of Maximal Impulse (PMI)
o Conductivity: ability to transmit an electrical impulse
*ICS- Intercostal space from one cell to another
*MCL- midclavicular line

CORONARY ARTERIES
1. Right Coronary Artery (RCA)
2. Left Coronary Artery
RIGHT CORONARY ARTERY (RCA)
 Supplies blood to:
o Right atrium and right ventricle
o Portion of the septum
o SA node & AV node
o Inferior portion of the left ventricle
LEFT CORONARY ARTERY
 Supplies blood to:
o CCA (Circumflex coronary artery)
o Left Atrium
o Posterior lateral surface of the left ventricle

 Left Anterior Descending Artery (LADA)

o Supplies blood to:
 Left ventricle
 Anterior septum
 Apex of the heart
CONDUCTION SYSTEM OF HEART
 The cardiac conduction system generates and transmits
electrical impulses that stimulate contraction of the
myocardium.
 Consists of:
o Sinoatrial (SA) node:
 the pacemaker; releases electrical impulses
 The impulses cause electrical stimulation and
subsequent contraction of the atria.
 located at the junction of the superior vena cava
and the right atrium
o Atrioventricular (AV) node
 Slowest conduction
 located in the right atrial wall near the tricuspid
valve
 coordinates the incoming electrical impulses from
the atria and after a slight delay (allowing the
atria time to contract and complete ventricular
filling) relays the impulse to the ventricles
o Bundle of His
 Branches into left and right bundle branch
 impulse is conducted then divided into the right
bundle branch (conducting impulses to the right
ventricle) and the left bundle branch (conducting
impulses to the left ventricle).
o Purkinje Cells
HEART PHYSIOLOGY
CARDIAC OUTPUT (CO)
 Is the blood volume the heart pumps through the systemic
circulation over a period measured in liters per minute
STROKE VOLUME
 Volume of blood pumped out of the left ventricle of the
heart during each systolic cardiac contraction
CARDIAC OUTPUT REAGULATION
 The heart pumps approx. 5L of blood every minute
 The heart rate increases with exercise therefore cardiac
output increases
 Cardiac output will vary according to the amount of venous
return
PRELOAD
 The degree of stretching of the heart muscle when it is
filled up with blood
 refers to the degree of stretch of the ventricular cardiac
muscle fibers at the end of diastole
AFTERLOAD
 the resistance to which the heart must pump to eject the
blood
 The resistance of the systemic BP to left ventricular
ejection is called systemic vascular resistance.

A.Y. 2023-2024 | BSN 3-B 2

 The resistance of the pulmonary BP to right ventricular  Murmurs (Erb’s Point)
ejection is called pulmonary vascular resistance.  Pericardial friction rub

CARDIAC CYCLE COMMON CLINICAL SIGNS & SYMPTOMS

 Diastole  Dysnea
o Relaxation phase o Difficulty on Exertion (DOE)
o all four chambers relax simultaneously, which allows o Orthopnea
the ventricles to fill in preparation for contraction. o Paroxysmal Nocturnal Dyspnea
o Diastole is commonly referred to as the period of o Cheyne-stokes respiration
ventricular filling.  Chest pain
 Edema
 Syncope
 Palpitations
 Systole  Fatigue (weak)
o Contraction
o refers to the events in the heart during contraction of
the atria and the ventricles.

CARDIAC ASSESSMENT LABORATORY TEST RATIONALE

 Interview  To assist in diagnosing MI
 Focused Assessment  To identify abnormalities
 Health History  To assess inflammation
o Obtain description of present illness & chief complaint  To determine baseline value
 Chest pain, DOB, Edema, etc  To monitor serum level of medications
 Assess Risk Factors (Predisposing factors  To assess the effects of medications
o Non-Modifiable
 Can’t control LABORATORY & DIAGNOSTIC STUDIES
 Age  CBC
 Gender
 Cardiac catheterization
 Race
 Lipid Profile
 Heredity
o Modifiable  Arteriography
 Stress  Cardiac enzymes & proteins
 Diet  CXR
 Exercise  ECG
 Cigarette Smoking  Holter Monitoring
 Alcohol  Exercise ECG
 Hypertension
 Hyperlipidemia
 Diabetes Mellitus
LABORATORY PROCEDURES
PHYSICAL EXAMINATION CARDIAC PROTEINS AND ENZYMES
INSPECTION: CK-MB (CREATINE KINASE)
 Skin Color  Elevates MI with in 4hrs, peaks in 18hrs and then declines
 Neck Vein Distention until 3 days
 Respiration  Normal value is 0-7 U/L
 Peripheral Edema LACTIC DEHYDROGENASE (LDH)
PALPATION  Elevates in MI in 24hrs peaks in 48-72hrs
 Peripheral Pulse  Normal value 70-200 IU/L
o Rhythm: Regular & Irregular MYOGLOBIN
o Amplitude of Rhythm  Rises within 1-3hrs
 Absent: 0  Peaks within 4-12hrs
 Weak: 1+ weak; diminish  Returns to normal in a day
 Normal: 2+ Normal TROPONIN I AND T
 Bound: 3+ Bounding
PERCUSSION  Troponin I is usually utilized for MI
 Elevates within 3-4hrs peaks in 4-24hrs and persist for
 Pulmonary Edema 7daysto 3 weeks
AUSCULTATION  Normal value: is less than 0.6ng/mL
 S1
 S2 SERUM LIPIDS

A.Y. 2023-2024 | BSN 3-B 3

 LIPID PROFILE HORIZONTAL
o measures the serum; cholesterol, triglycerides and to V₄
lipoprotein levels V₆ VIOLET LMAL LATERAL &HORIZONTAL
 Cholesterol: <200 mg/dL to V₄
 Triglycerides: 40-150mg/dL
 LDL: 130 mg/dL
 HDL-30-70mg/dL
 NPO: post-midnight (usually 12hrs)

BLOOD COAGULATION TEST

PROTHROMBIN TIME (PT, PRO TIME)
 Measures the time required for a clot to occur after
thromboplastin and calcium are added to decalcified the
plasma
 Elevates the effectiveness of Coumadin
o Coumadin is an anticoagulant, the patient will lead to
bleeding
 Vitamin K- to prevent bleeding; the antidote of coumadin
 Normal range: 11-12 seconds

PARTIAL THROMBOPLASTIN TIME (PTT)

 Measures the time required for the clot to occur after a
partial thromboplastin, reagent is added to blood plasma
HOLTER MONITORING
 Elevates the effectiveness of Heparin
 Non- invasive test in which the client wears a Holter
 Antidote of heparin; Protamine Sulfate
monitor and an ECG tracing recorded continuously over a
 Normal Range: 60-70 seconds period of 24hrs
ACTIVATED PARTIAL THROMBOPLASTIN TIME  Instruct the client to resume normal activities and maintain
(APTT) a diary of activities and any symptoms that may develop
 Same purpose with PTT (HEPARIN)
 Evaluate the effectiveness of heparin ECHOCARDIOGRAM
 Normal range: 30-45 seconds  Non – invasive test that studies the structural and
 Antidote: Protamine Sulfate functional changes of the heart with the use of ultrasound
or soundwave
ELECTROCARDIOGRAM (ECG)  No special preparation needed
 Non- invasive procedure that evaluates the electrical
activity of the heart STRESS TEST
 First diagnostic test done when cardiovascular disorder is  A non-invasive test that studies the heart during activity
suspected detects and evaluate CAD
NURSING RESPONSIBILITIES:  Treadmill testing (common tool)
o Skin should be dry  Used to determine CAD, chest pain causes, drug effects
o Avoid hairy areas and dysrhythmias in exercise
o Avoid movement PRE-TEST
 Consent may be required
LIMB LEADS  Adequate rest
RA RED RIGHT ARM  Eat only light meal or fast for 4hrs
 Avoid smoking/alcohol/caffeine
LA YELLOW LEFT ARM
LL GREEN LEFT LEG POST TEST
RL BLACK RIGHT LEG  Instruct the patient to notify the doctor/physician for: chest
pain/dizziness/ SOB
 Instruct the client to avoid taking a hot shower for 10-12hrs
CHEST LEADS after the test
V₁ RED 4th ICS
V₂ YELLOW 4th ICS CORONARY ANGIOGRAPHY/ANTERIOGRAPHY
V₃ GREEN Midway between V₂&V₄  invasive procedure
 Physician will inject dye into coronary artery
V₄ BROWN 5th ICS LMCL
V₅ BLACK LAAL LATERAL &

A.Y. 2023-2024 | BSN 3-B 4

 Immediately takes a series of CXR to assess the structure
of the arteries
NURSING RESPONSIBILITIES
 Pre-test:
o Obtain written consent
o Explain procedure
o Assess client for history of allergies to dye/ shellfish
 Post-test:
o Initiate IV site with fluids as order
 Increase fluid intake to excrete the dye as the
dye can damage the kidney (nephrotoxicity)
PERCUTANEOUS TRANSLUMINAL CORONARY
ANGIOPLASTY (PTCA)
 Is a technique used to dilate an area of arterial blockage
with the help of a catheter that has an inflatable small
sausage shaped balloon at its tip (in order for the blood to
flow)
PURPOSE:
 To improve blood flow with in a coronary artery by
cracking the atheroma(cholesterol)
CORONARY ARTERY BYPASS GRAFTING (CABG)
 A surgical procedure wherein arteries or veins from
elsewhere of the body are grafted to the coronary arteries
to bypass atherosclerotic narrowing and improve blood
supply to the coronary circulation
NURSING RESPONSIBILITY:
 Client Preparation
o Instruct the patient in routine preoperative teaching,
turning and deep breathing
o Vigorous coughing is discouraged, it may increase
intrathoracic pressure and cause instability in the
sterna area
o Incentive spirometry to prevent respiratory
complication
o Leg exercise to prevent emboli formation
 Emboli: goes with circulation; brain, lungs, heart
 Thrombus: permanent clot; stay in one location
POST PROCEDURE
 Instruct that client may resume sexual activity when
he/she can walk up to full flights of stairs without shortness
of breath or chest pain
 Client should be rested, not after a heavy meal/ alcohol
consumption
 Instruct client about symptoms to report to doctor upon
discharge including chest pain, SOB, decrease activity
tolerance, fever, redness, swelling or drainage from
surgical incisions
 Instruct the client that clinical depression occurs in about
20% of clients up to 6 months after cardiac surgery and
client should report to the physician because anti-
depressant is very effective including family in health
teaching planning for discharge
 Instruct the patient that many patients have difficulties in
cognitive function after the procedure
 Reassure patient and family that the difficulty is temporary
& will subside usually 6-8 weeks
HEMODYNAMIC MONITORING
CARDIAC CATHETERIZATION
 Insertion of a catheter into the heart and surrounding
vessel
 Used to monitor/check the pressures on different
chambers of the heart
 Usually performed with angiography
 Used to diagnose CAD
 Asses the coronary artery pathway
 Determine the extent of atherosclerosis
 Right cardiac catheterization is commonly used by
surgeons!
NURSING RESPONSIBILITIES
PRE-TEST
 Consent
 Asses for allergy to seafood and iodine
 NPO
 Document weight & height, baseline, VS, blood test,
peripheral pulses
INTRA TEST:
 Inform the patient of a fluttery feeling as the catheter
passes through the heart
 Inform the patient that feeling of warmth and metallic task
may occur when dye is administered
POST TEST:
 Monitor VS & cardiac rhythm
 Monitor the peripheral pulses, color warmth and sensation
of the extremity distal to insertion site.
 Maintain sandbag to the insertion site if required to
maintain pressure
 Monitor for bleeding and hematoma formation
 Maintain strict bed rest for 6-12hrs
 Client may turn from side to side but bed should not be
elevated more than 30 degrees legs always straight
 Encourage fluid intake to flush out the dye
 Immobilize the arm if the antecubital vein is used
 Monitor for dye allergy
CENTRAL VENOUS PRESSURE (CVP)
 The CVP is the pressure within the superior vena cava
(SVC)
 Reflects the pressure under which blood is return to the
SVC and right atrium
NORMAL CVP
 0 to 8 mmHg
A.Y. 2023-2024 | BSN 3-B 5
 4-10 cmH2O  If 50% of the left coronary arterial lumen is reduced or
75% of the other coronary artery this becomes significant
ELEVATED CVP INDICATES:  Potential for thrombosis and embolism
 Increase in blood volume (with in the blood)
 Excessive IVF heart/renal failure ANGINA PECTORIS
 Transient, paroxysmal chest pain produced by insufficient
LOW CVP MAY INDICATE: blood flow to the myocardium resulting in myocardial
 Hypovolemia ischemia
 Hemorrhage PRECIPITATING FACTORS:
 Severe vasodilation  Physical exertion
 Environment
MEASURING CVP  Eating heavy meals
1. Position the client supine with the bed elevated at 45  Excitement (emotion)
degrees
2. Position the zero point of the CVP line at the level of the 3 TYPES:
right atrium. Usually this is at the 4th ICS STABLE ANGINA:
3. Instruct the client to be relaxed and avoid coughing and
 Typical angina occurs during exertion relieved by rest ang
straining
drug and the security does not change (pain scale is
stable)
CORONARY ARTERY DISORDER (CAD)
 Results from the focal narrowing of the large & medium UNSTABLE ANGINA:
sized coronary arteries due to deposition of atheromatous
plaque in the vessel wall  Occurs unpredictability during exertion and emotion
severity increases with time, and pain may not be relieved
RISK FACTORS: by rest and drug
 Age above 45/55 and sex- males and post- menopausal
females VARIANT ANGINA:
 Family history  Prinzmetal angina
 Hypertension  Results from coronary artery VASOSPASMS may occur
 DM rest or at night
 Smoking
 Obesity ASSESSMENT FINDINGS
 Sedentary lifestyle  Chest Pain -Angina
 Hyperlipidemia o Most characteristic symptom
o Pain is described as mild to severe retrosternal; pain
MOST IMPORTANT MODIFIABLE FACTORS squeezing, tightness or burning sensation
 Smoking o Radiates to the jaw and left arm
 Hypertension o Precipitated by:
 Diabetes  Exercise
 Cholesterol abnormalities  Eating heavy meals
 Emotions (excitement &anxiety)
 Extremes and temperature
 Relieved by rest or nitroglycerin
PATHOPHYSIOLOGY  Diaphoresis
 Nausea and Vomiting
Fatty streak formation in the vascular  Cold Clammy skin
 Sense of Apprehension &Doom
T cells and monocytes ingest lipids in the area of deposition  Dizziness and Syncope (fainting)

LAB FINDINGS
Atheroma
ECG
 Ischemic changes may slow ST depression and T wave
Narrowing of the Arterial Lumen
inversion
CARDIAC CATHETERIZATION
Reduced coronary blood flow
 produces most definitive source of diagnosis by showing
the presence of the atherosclerotic lesion
Myocardial Ischemia
NURSING DIAGNOSIS
 Decreased perfusion of myocardial tissue and inadequate  Decreased cardiac output
myocardial oxygen supply  Impaired gas exchange

A.Y. 2023-2024 | BSN 3-B 6

 Activity intolerance  ASPIRIN- to prevent thrombus formation
 Anxiety o Nursing Responsibility:
 Asses for bleeding
NURSING MANAGEMENT  Avoid straining the stool
 Stop all the activities (REST)  ASA should be given with food
 Semi- Fowlers Position  Observe for ASA toxicity(tinnitus)
o Decrease workload on the heart
 Administer prescribed medications MYOCARDIAL INFARCTION
o NITRATES (NITROGLYCERINE)  Death of myocardial tissue in regions of the heart with
 To dilate the venous vessels decreasing venous abrupt interruption of coronary blood supply
return and to some extent dilate coronary
o Nursing responsibilities (when giving nitroglycerine): Interrupted coronary blood flow
 Sitting/ Supine Position
 Give 3 doses at 5 minutes interval then refer
myocardial ischemia
 It effects 1-3 minutes, duration:15-30 mins
 Sublingual causes burning sensation
 Advise the client to always carry 3 tablets
anaerobic myocardial metabolism for several hours
 Store nitroglycerine in a cool, dry place, use
amber colored airtight container
 Do not store in refrigerator myocardial death
 Change stock every 3-6 months
o Nitroglycerine Patch
 Long acting (12-24hrs) depressed cardiac function
 Patch on (daytime) and patch off (night time)
 Should be rotated on the chest wall
o Side Effect
ASSESMENT FINDINGS
 HA
 Warm sensation under the tongue  Chest pain
 Flushing o Severe, persistent, crushing, substernal discomfort
 Orthostatic hypotension o Radiates to the neck, arm, jaw and back
o Occur without cause, primarily early in the morning
o BETA BLOCKER o NOT relieved by rest or nitroglycerine
 Beta Blockers to reduce BP and HR o Last 30 minutes or longer
 Mechanism of action: stop sympathetic nervous  Dyspnea
system  Diaphoresis
o Side effect:  Cold clammy skin
 Bradycardia; atropine sulfate  Nausea and vomiting
 Hypotension  Restlessness, sense doom
 Muscle weakness  Tachycardia &bradycardia
o Nursing Responsibilities:  Hypotension
 Asses pulse rate o S3 and Dysrhythmias
 Administered with food
 Do not propranolol to patient with; LABORATORY FINDINGS:
 Asthma  ECG
 DM o ST segment is elevated
o T wave inversion
o CALCIUM CHANNEL BLOCKERS:
o Presence of abnormal Q wave
 To dilate coronary artery and reduce vasospasm
 Myocardial Enzymes
 Mechanism of Action:
o Elevated CK-MB, LDH, and Troponin levels
 Block entry of calcium preventing contraction
 Artery has 3 layers  CBC
o may show elevated WBC count
 when muscle contract calcium and sodium
enter then potassium exits  Test after the acute stage
 Opposite happens during muscle relaxation o exercise tolerance test thallium scan cardiac
catheterization
o Side effects of Calcium Channel Blockers:
 Hypotension
 Constipation
 Bradycardia
 GI Complaints
NURSING DIAGNOSIS FOR MI:
o ANTIPLATELETS  Pain

A.Y. 2023-2024 | BSN 3-B 7

 Decreased cardiac output
 Impaired gas exchange
 Activity intolerance
 Altered tissue perfusion

NURSING INTERVENSION
 Provide Oxygen at 2L/m, semi fowler’s
 Administer medications
o Morphine to relieve pain
o Nitrates
o Thrombolytics (destroys clot)
 Streptokinase, Urokinase, Tissue Plasminogen
Activator (TPA)
 Be given 3 to 6hrs after the initial infarction.
 Asses for bleeding
o Anticoagulants & Antiplatelet (Aspirin)
 Given after thrombolytic therapy
o ACE Inhibitors
 Relax the veins and arteries to lower BP
o Stool Softener
 Works by releasing the amount of water the stool
absorbs in the gut, making the stool softer and
easier to pass
o Antilipidemic
 Promote reduction of lipid levels in the blood
 Minimize patient anxiety
 Provide adequate rest periods
o bed rest during acute stage
 Minimize metabolic demands
o Provide soft diet
o Provie a low – sodium, low cholesterol, and low-fat
diet
 Assist in treatment modalities such as PTCA & CABG
 Monitor for complications of MI
o especially dysrhythmias, since ventricular tachycardia
can happen in the first few hours after MI
 Provide client teaching

NURSING MANAGEMENT FOR MI

 MONA:
o Morphine
o Oxygen
o Nitroglycerine
o Aspirin
 OMNA:
o Oxygen
o Morphine
o Nitroglycerine
o Aspirin

A.Y. 2023-2024 | BSN 3-B 8