¨ Heart

¨ Lungs

¨ Red Blood Cells

¨ Blood Vessels
¨ Heart
¡ cone-shaped
hollow muscular
organ located in
the mediastinum
between the lungs
¡ Pumps about
60ml/beat or
5L/min
¡ Pericardium –
protective covering
of the heart
¨ 3 layers of cardiac muscle tissue:
¡ Epicardium– outermost layer
¡ Myocardium – middle layer
¡ Endocardium – innermost layer
¨ Chambers
¡ Right atrium (0-5
mmHg)
 SVC, IVC, Coronary
sinus
¡ Right Ventricle
(25 mmHg)
¡ Left atrium
¡ Left ventricle
¨ Valves
¡ AV valves
¡ Semilunar
valves
¨ Coronary arteries
¡ Left Coronary Artery
 Left anterior descending – LV, Ventricular septum, chordae
tendinae, papillary muscle, RV (lesser extent)
 Circumflex coronary artery – LA, lateral & posterior surfaces of
LV, portion of interventricular septum, SA node, AV node
¡ Right Coronary Artery
 RA, RV, inferior portion of LV

Branching pattern of the coronary

arteries varies considerably
among individuals
¨ Electrophysiologic Properties of the Heart
¡ Automaticity
 initiate an impulse spontaneously & repetitively
¡ Excitability (depolarization)
 respond to a stimulus
¡ Conductivity
 Transmit electrical impulses
¡ Contractility
 Contract
¡ Refractoriness
 Inability to respond until repolarization
¨ Conduction System
of the Heart
¡ SA node (60-100
times/min)

¡ AV node (40-60
beats/min)

¡ Bundle of His
¡ R & L bundle
branches
¡ Purkinje fibers
(20-40 beats/min)
¨ Sequence of events
during cardiac cycle

¡Systole (contraction)
– emptying

¡Diastole (relaxation)
– filling
Mechanical Properties of the Heart
¨ Cardiac Output
HR
Cardiac Output = HR x SV
¡
 ANS, # endogenous cathecolamines
 Parasympathetic NS (vagus nerve), beta blockers, Ca++-
channel blockers
¡ SV
 Preload – volume of blood distending the ventricles at the end
of diastole just before contraction
 Afterload – resistance that the ventricles must overcome to
eject blood
 Contractility
¨ Vascular System
¨ Vascular System
¨ Vascular System: FUNCTIONS
¡ Provide conduits for blood to
travel from the heart to nourish the
various tissues of the body
¡ Carries cellular waste to the
excretory organs
¡ Allows lymphatic flow to drain
tissue fluid back into the
circulation
¡ Returns blood to the heart for
recirculation
¨ Vascular System
¨History (focus: obtaining
information about client’s risk
factors & symptoms of
cardiovascular disease)
¡ Demographic data – age, gender, ethnic origin
¡ Family history & genetic risk
¡ Personal history
¡ Diet history
¡ Socioeconomic status
 History
¨History

Modifiable
¡ Modifiable

cigarette
cigarettesmoking
smoking
physical inactivity
physicalinactivity
Obesity
Obesity
psychological variables
psychologicalvariables
chronic
chronicdiseases
diseases
¡ Non-modifiable risk factors
 Non-modifiable risk factors
age, gender, ethnic background, family
age,gender,ethnicbackground,family
history
history
¨cigarette smoking –
major risk factor for the devp’t
of CAD & PVD
¨ Obesity–strongindicatorof
CVDespeciallywhen
abdominalobesityispresent
¨ Physical assessment
¡ Major symptoms cardiovascular disease (CVD)

 Pain or discomfort
 Dyspnea (DOE, Orthopnea, Paroxysmal Nocturnal
Dyspnea)

 Fatigue
 Palpitations
 Weight gain – best indicator of fluid retention (edema)
 Syncope – transient loss of consciousness ($ cerebral
perfusion)

 Extremity pain – due to ischemia & venous insufficiency

¨ Physical assessment
¡ Skin color – pallor (anemia), cyanosis (late sign of
decreased perfusion)
¡ $ skin temperature – due to $ blood flow
¡ Clubbing of fingers – chronic tissue hypoxia
¡ Edema
¡ BP changes
 Hypertension
 Postural
Hypotension
¡ Pulse pressure
(30-40mmHg)
Precordium (area over the
heart)
Assessment involves:
¡ Inspection
 Apical impulse
¡ Palpation
¡ Percussion
¡ Auscultation
 Normal heart sounds
 Abnormal heart sounds
¨ Normal Heart Sounds

¡ S1 – closure of AV valves
 Low pitch, long; best heard at the
apex of the heart
 Palpate the carotid pulse while
listening
 Marks the beginning of ventricular
systole

¡ S2 – closure of semilunar valves

 High pitch, short; best heard at the
base of the heart
Abnormal Heart Sounds
¨ Murmurs
¡ Reflection of turbulence of blood
flow through the normal or
abnormal valves
¨ Pericardial friction rub
¡ Sign of inflammation, infection or
infiltration
Laboratory Tests
¨ Serum markers of myocardial damage (cardiac
markers)
¡ Troponin (T=<0.2ng/ml, I=<0.03ng/ml)
¡ CreatineKinase (CK-MB)
¡ Myoglobin (<90mcg/L)
¨ Serum lipids
¡ Cholesterol (122-200mg/dl), TGL ( 40-160 35-
135mg/dl)
¡ HDL ( 45-50 55-60mg/dl), LDL ( 60-180mg/dl)
¡ HDL:LDL ratio (3:1)
¨ Laboratory Tests
¡ C-Reactive Protein (<1.0mg/dl)
¡ Blood coagulation tests (evaluatetheabilityofthebloodto
clot-thrombi)
¡ ABG
¡ Serum electrolytes (K+, Ca++, Na+, Magnesium)
¡ CBC
¨ Radiographic
examinations

¡ Chest
radiography
 Determine the size,
silhouette & position of the
heart

¡ Angiography
(arteriography)
 Invasive procedure
involving fluoroscopy & the
use of contrast media
¨ Cardiac catheterization
 Most definitive, most
invasive test used in the
diagnosis of heart disease
¡ Right-sided heart
catheterization
¡ Left-sided heart
catheterization
Angiography in action: The beating heart and its
surrounding blood vessels can be watched and
recorded in extraordinary detail as a catheter injects
a contrast dye into a patient's coronary arteries
¨ Coronary arteriography
¡ Technique is the same for left-sided heart catheterization
¡ Complications: MI, Stroke, Arterial bleeding,
Thromboembolism, Lethal dysrhythmias, Death
¨ Intravascular ultrasonography (IVUS)
¡ Catheter with miniature transducer (soundwaves) at the
distal tip to visualize the coronary arteries
¨ Electrocardiography (ECG)
¡ graphically measures & records
the electrical current traveling
through the conduction system
generated by the heart
¡ measured by electrodes placed on
the skin & connected to an
amplifier & strip chart recorder
¡ in a standard 12-lead ECG:
 five electrodes attached to the
arms, legs, & chest
 measures electrical current from 12
different views or leads
¨ Bipolar limb leads
¡ Lead I
¡ Lead II
¡ Lead III
¨ Unipolar augmented leads
¡ aVR
¡ aVL
¡ aVF
¨ Unipolar precordial leads
¡ V1
¡ V2
¡ V3
¡ V4
¡ V5
¡ V6
¨ Bipolar limb leads
¡ Lead I
¡ Lead II
¡ Lead III
¨ Unipolar augmented leads
¡ aVR
¡ aVL
¡ aVF
¨ Unipolar precordial leads
¡ V1
¡ V2
¡ V3
¡ V4
¡ V5
¡ V6
¨ Unipolar precordial leads
¡ V1
¡ V2
¡ V3
¡ V4
¡ V5
¡ V6
Electrocardiographic Paper
¨ electrocardiogram (ECG) strip: each small block
measures 1 mm in height & width
¨ standard speed:25mm/sec
¡ 1 small block = 0.04 sec 1 large block = 5 small blocks
¡ 1 large block = 0.20 sec 5 large blocks = 1 sec
¡ 15 large blocks = 3 sec 30 large blocks = 6 sec
¨ P wave – represents atrial depolarization
¨ PR segment – represents the time required for the impulse to
travel through the AV node, where it is delayed, and through
the Bundle of His, Bundle branches, & Purkinje fiber network,
just before ventricular depolarization
¨ PR interval – represents the time required for atrial
depolarization as well as impulse travel through the
conduction system and Purkinje fiber network, inclusive of the
P wave and PR segment. It is measured from the beginning of
the P wave to the end of the PR segment (0.12-0.20 sec)
¨ QRS complex – represents ventricular depolarization and is
measured from the beginning of the Q (or R) wave to the end
of the S wave (0.04 - 0.10 sec)
¨ ST segment – represents early ventricular repolarization
¨ T wave – represents ventricular repolarization
¨ U wave – represents late ventricular repolarization
¨ QT interval – represents the total time required for ventricular
depolarization and repolarization and is measured from the
beginning of the QRS complex to the end of the T wave
Characteristics of the Normal rhythm:
¨ HR is 60-100 bpm

¨ P waves are found BEFORE the QRS complex

¨ PR interval is 0.12 to 0.20 seconds duration

¨ QRS complex is 0.04 to 0.10 seconds duration

¨ conduction is forward and cyclical

¨ The rhythm is regular with no delay

¨ Various forms of ECG
¡ Resting ECG
¡ Ambulatory ECG (Holter
monitoring) – 24 hrs.
¡ Exercise ECG (Stress test)
¨ Echocardiography
¡ uses ultrasound waves to assess cardiac structure &
mobility, particularly at the valves
¨ Hemodynamic Monitoring
¡ Use to assess the volume & pressure of blood in the
heart & vascular system by means of a surgically
inserted catheter
Methods:
¡ Direct BP monitoring
 Artery used: radial, brachial, femoral
 Catheter tip contains sensor that measures & transmits the
fluid pressure to a transducer
¡ CVP monitoring
¡ Pulmonary artery pressure monitoring
¨ CVP monitoring
¡ Pressure produced by venous blood in the RA
¡ NV: 2-7 mmHg or 4-10cm H2O
¨ Pulmonary artery pressure monitoring
¨ Infectious Disorders
¡ Pericarditis, Myocarditis, Endocarditis, RHD
¨ Coronary Artery Disease
¡ Atherosclerosis
¡ Angina pectoris
¡ Myocardial infarction
¨ Congestive Heart Failure
¨ Pulmonary edema
¨ Arrythmias
¨ Inflammation of the pericardium
Associated w/ the following:
¡ Malignant neoplasms
¡ Idiopathic cause
¡ Infective organisms (bacteria, viruses, fungi)
¡ Post-MI syndrome (Dressler’s syndrome)
 pericarditis, fever, pericardial & pleural effusion 1-12 weeks
after MI)
¡ Postpericardiotomy syndrome
¡ Systemic connective tissue disease
¡ Renal failure
Chronic pericardial inflammation causes fibrous
thickening of the pericardium
¨ “Chronic Constrictive Pericarditis”

rigid pericardium

inadequate
ventricular
filling

Heart Failure
¨ Assessment:
¡ PAIN radiating to the neck, shoulder & back
 aggravated by inspiration, coughing & swallowing
 worst in supine position (relieved by sitting up & leaning
forward)
¡ Pericardial friction rub (scratchy high pitch sound)
¡ If w/ chronic constrictive pericarditis: Signs of RSHF
¡ Echocardiography, CT scan – reveals thickening of
pericardium
¡ #WBC count
¡ Atrial fibrillation is also common
¨ Interventions:
¡ NSAIDs for PAIN
¡ Corticosteroids
¡ Antibiotics
¡ Pericardial drainage
¡ Radiation or chemotherapy if caused by malignancy
¡ Hemodialysis (uremic pericarditis)
¡ Assist to assume position of comfort
¡ Pericardiectomy (chronic constrictive pericarditis)
¡ Monitor for complications: pericardial effusion
Monitor for complications:
¨ pericardial effusion  cardiac tamponade
Findings:
¡ Jugular distention
¡ Paradoxical pulse
(systolic BP 10mmHg
or more on expiration
than on inspiration)
¡ $ cardiac output
¡ Muffled heart
sounds
¡ Circulatory collapse
¨ emergency care: pericardiocentesis
Causes:
¡ Viral, bacterial, fungal & parasitic infection
¡ Chronic alcohol & cocaine abuse
¡ Radiation therapy
¡ Autoimmune disorders
¡ Bulimic patients taking ipecac syrup to
facilitate purging (myocardial damage)
¨ Due to inflammation  abnormal
function
¡ $ cardiac output, impaired blood circulation,
predispose client to CHF
¡ Due to ischemia: tachycardia, dysrhythmias
¡ Cardiomyopathy
¨ Assessment:
¡ PAIN, Fever, Tachycardia,
Dysrhythmias, Dyspnea,
Malaise, Fatigue, Anorexia,
Pale or cyanotic skin, signs
of RSHF
¡ #WBC count, elevated CRP,
elevated cardiac isoenzymes,
abnormal ECG
¡ Abnormal chest radiography,
echocardiography
¨ Intervention:
¡ Treatment of underlying cause (antibiotic)
¡ Promote bed rest, Na+-restricted diet, cardiotonic drugs
(digitalis) are prescribed
¡ Monitor cardiopulmonary status and complications (CHF,
dysrhythmias)
 VS
 Daily weight
 I&O
 Heart & lung sounds
 Pulse oximetry measurements
 Cardiac monitoring
 Dependent edema
¡ A systemic inflammatory disease that usually
develops after an URTI
¡ group A ß-hemolytic streptococci
¡ Rheumatic carditis (Rheumatic endocarditis)
 Antibodies are formed to destroy the group A ß-
hemolytic strep microorganism

Antibodies “mistakenly” cross-react against the proteins

in the connective tissue of the heart, joints, skin &
nervous system

PanCARDITIS (all layers)

due to inflammation, WBC migrate to endocardium causing
accumulation of inflammatory debris “vegetations” around
the valve leaflets
Assessment:
¨ Major/ Classic symptoms

¡ Carditis
¡ Polyarthritis
¡ Chorea (Sydenham’s chorea, St. Vitu’s dance)
¡ Subcutaneous nodules
¡ Erythema marginatum
Assessment:
Major/ Classic symptoms
¨ Carditis
¡ Characterized by
formation of Aschoff’s
bodies
¡ Murmur (valve damage)
¡ pericardial friction rub
(pericarditis)
¡ CHF
Assessment:
Major/ Classic symptoms
¨ Polyarthritis
¡ Swelling of several joints (knees, ankle, hips,
shoulders) that is warm, red and painful
¨ Chorea (Sydenham’s chorea, St. Vitu’s
dance)
¡ Involuntary grimacing & inability to use
skeletal muscles in a coordinated manner
¡ Involvement of CNS
Assessment:
Major/ Classic symptoms
¨ Subcutaneous nodules
¡ Sometimes marble-sized nodules
appear around the joints
¨ Erythema marginatum
¡ Red, spotty rashes on the trunk
that disappears rapidly leaving
irregular circles on the skin
Assessment:
¨ Minor symptoms
¡ Reliable history of RF or evidence of pre-existing
rheumatic heart disease
¡ Arthralgia- pain in one or more joints without evidence of
inflammation, tenderness, or limited movement
¡ Fever (38.9 - 40°C or 101 - 104°F)
¡ Diagnostic tests: in ESR and ASO titer, (+) C- reactive
protein
¡ ECG changes: prolonged P-R interval
¨ Diagnosed clinically
through the use of the

JONES
criteria
¡ presence of 2 major
manifestation or
¡ 1 major + 2 minors
with supporting evidence of
a recent streptococcal
infection
¨ Management/ Intervention:

¡PREVENTION - ideal management

early identification &
 RHD is prevented through
adequate treatment of streptococcal
infection

 A nurse should be familiar with the signs

&
symptoms of streptococcal pharyngitis
Signs & symptoms of streptococcal pharyngitis:
¡ Fever (38.9 - 40°C or 101 - 104°F)
¡ Chills
¡ Sore throat (sudden onset)
¡ diffuse redness of throat with exudates on oropharynx
Signs & symptoms of streptococcal pharyngitis:
¡ Enlarge & tender lymph nodes
¡ Abdominal pain ( common in children)
¡ Acute sinusitis & acute otitis media
¨ Management/ Intervention:
¡ Antibiotic: DOC – penicillin
¡ Aspirin (control blood clot formation around the valves)
¡ Steroids (suppresses inflammation)
¡ Fever (antipyretics, hydration)
¡ Antibiotic prophylaxis to prevent recurrence
¡ Provide bed rest; provide diversional activities that require
minimal activity (reading, putting puzzles together)
¡ Assess for progression or improvement of heart
involvement
¨ Infectious Disorders
¡ Pericarditis, Myocarditis, Endocarditis, RHD
¨ Coronary Artery Disease
¡ Atherosclerosis
¡ Angina pectoris
¡ Myocardial infarction

¨CongestiveHeart Failure
¨Pulmonary edema
¨ Arrythmias
¨ “Pump failure”, inadequacy of the heart to pump
blood throughout the body
¨ Congestive Heart Failure
¡ accumulation of blood & fluid in organs & tissues due to
impaired circulation
¨ Types:
¡ Left-sided heart failure
¡ Right-sided heart failure
¨ Causes:
¡ Damage to muscular wall (M.I.), Cardiomyopathy,
Hypertension, CAD, Valvular defects, Infections
Left = Lungs
¨ Diagnostic Findings:
¡ Chest x-rays: reveals cardiomegaly
(hypertrophy)
¡ Pleural effusions develops
¡ ECG: abnormal findings (ventricular
hypertrophy, dysrhythmias)
¡ Echocardiography – reveals cardiac
valvular changes, pericardial effusions,
chamber enlargement, ventricular
hypertrophy
¡ Multigraded angiographic (MUGA)
scans – information about ejection
fraction
Medical Management:
¨ Low-sodium diet, fluid restriction

¨ Inotropic agents:
¡ Digitalis: Digoxin (Lanoxin)
 # contractility, $ HR, $ conduction (AV node)
 (-) sympa. activity, (+) parasympa. Activity
 Watch out for DIGITALIS toxicity: loss of apetite,
N&V, rapid, slow, irregular heart rate,
disturbance in color vision
¡ Dopamine (Intropin), Dobutamine (Dobutrex)
¨ Diuretics: Furosemide (Lasix), Chlorothiazide (Diuril)
¨ Vasodilators (Nitroglycerin), ACE inhibitors (pril)