CARDIOVASCULAR SYSTEM

THE HEART (The Pump)

Apex

• In between your parietal and

visceral pericardium is a
serous fluid-filled pericardial
cavity which allows the heart
to beat easily without friction.

HEART:

• • Location: Thorax,
mediastinum
• Thus: Heart surgery also
called thoracic surgery
• The Apex is pointed towards
your left hip and rests on the
diaphragm, approximately at the level
of the fifth intercostal space. (This is
exactly where one would place a
stethoscope to count the heart rate for
an apical pulse) • Pericarditis – inflammation of
• The size of your heart is as big astheyour
pericardium
fist results in a
decrease in the amount of
• Coverings/layers: serous fluid which causes the
pericardial layers to rub
• Pericardium (covers the heart)
forming painful adhesions.
1. Parietal – outer part, hard and fibrous
2. Visceral – inner part or heart wall, consist of:
a) epicardium – protective layer, serous membrane
with connective tissue covered by epithelium
b) Myocardium - thick cardiac muscle which contracts
c) Endocardium –is a thin, glistening sheet of endothelium
that lines the 4 chambers; it contains elastic and
collagenous fibers as well as Purkinje fibers which
are specialized muscle fibers that conduct cardiac
impulses
• Chambers: Right Side Left Side
• 2 Atria = Receiving blood - to pulmonary System thru - to Systemic Circulation thru
• 2 Ventricles = Discharging Pulmonary Artery Aorta
blood • Tricuspid Valves = connects the • Bicuspid/Mitral Valves =
• Septum = Wall Divisions RA to the RV; 3 cusps connects the LA to the LV;
2 cusps
• The• Arteries = carries
heart valves open and
2
O blood
close passively •because
Semilunar Valve = Pulmonary
of pressure • Pulmonary Vein – carries O2
• Veins =oncaries
differences eitherdeO
2
sideblood
of the valve. WhenArtery – carries
pressure 2
deObehind
is greater blood from blood from Lungs to LA
• Except for: RV to Lungs for
the valve, the leaflets are blown open and the blood flows through theoxygenation
•
valve. However, when pressure
Pulmonary • Superior
is greater in
Artery front of the valve, the
& Inferior Vena Cava = • Semilunar Valve = Aorta –
leaflets snap shut and blood
2
= carries deO blood flow is stopped. The motion 2 of a heart valve
carries deO blood from LUB the body carries O2 blood
DUBfrom LV to
is analogous
• to thePulmonary
motion of Veins
the front door of yourRA
to the house. The 1 -door,
ST
(S 1 heart sound) systemic2 circulation
ND
(S - 2 heart sound)
which only= opens
carriesinOone
2 direction, opens and closes due to pressure
blood on
1. Closure of the AV 2. Closure of the
the door. valves (atrioventricular semilunar valves
• Tricuspid side (pulmonic and
• Mitral side aortic valves)
 • Are responsible for the unidirectional flow of blood (one direction)
• Also responsible for your heart sounds
* If any part of the heart muscle is
• Normal heart sounds are caused by the closing of
deprived of its blood supply
heart valves. As valves snap shut, the walls of the
through interruption of blood
chambers and major arteries vibrate. We hear these
flow through the coronary
vibrations as two distinct sounds; LUB-DUB.
arteries and their branches, the
muscle tissue deprived of blood
• In valvular stenosis – the valve flaps become cannot function and will die.
incompetent, they become stiff, often because of This is called myocardial
endocarditis (bacterial infection of the infarction (MI).
endocardium). This forces the heart to contract more
vigorously than normal. The heart’s workload
increases, and ultimately the heart weakens and may
fail. Under such conditions the faulty valve is
replaced with a synthetic valve or a valve taken from
a pig heart. •• BLOOD SUPPLY of the heart is via
(coronary circulation):
1. First 2 branches of the aorta,
2. left and right coronary arteries
• These arteries arise
from the base of the aorta
and encircle the heart in
the atrioventricular

Right coronary artery:

• Posterior interventricular
artery - runs to the apex and
supplies blood to the posterior
ventricular walls
• Marginal artery - supplies
blood to the myocardium of
the right side of the heart

groove.

•
Left coronary artery: From the
• anterior interventricular arteries it
artery - supplies blood to the will go
interventricular septum and to your
anterior walls of both capillary
ventricles networks
• circumflex artery - capilla
supplies blood to the left ry veins
atrium and the posterior

walls of the left ventricle
coronary sinus drains to atrium of the
heart.

• Veins: Small, middle, and great cardiac veins

leading to coronary sinus
• The myocardium needs a constant supply of
oxygen in order for the heart to continually
pump. Myocardium capillaries are branches
of cardiac veins which join to form the
coronary sinus, an enlarged vein which
empties into the right atrium.
• Although a tremendous amount of blood flows
through the chambers of the heart, this blood does
not nourish the heart. The heart is nourished by
blood from the coronary circulation, a system of
arteries, capillaries and veins that brings blood to all
of the tissues of the heart. The graphic above
identifies arteries (red) supplying oxygenated blood
to the heart tissue, and veins (blue) removing
deoxygenated blood. Coronary artery disease is
associated with reduced blood flow to these vessels.
 • NERVE SUPPLY of the heart: Medulla (cardiac center)
• Vagus nerve – help regulate heart activity; it lowers heart rate (parasympathetic)
o In contrast Sympathetic Nerve will increase HR and cardiac output
• Conduction System: to electrical impulses it will create a contraction….SA Node

PHYSIOLOGY OF THE HEART

 CARDIAC OUTPUT
• The volume of blood ejected by each ventricle in one minute
• CO = Stroke Volume (SV) X Heart Rate (HR)
• Stroke Volume – the amount of blood ejected by the left ventricle with each heartbeat
 Preload – the end diastolic filling volume of the ventricle, increases by increased returning volume to
the ventricle
 Afterload – the resistance to left ventricle ejection; increases by increased systemic arterial pressure
• Heart Rate – the number of heartbeats per minute; normal heart rate is 60 to 100 bpm

 CARDIAC CYCLE
• Each complete heartbeat consists of two phases; N = 0.8 Seconds
 Systole – the contraction phase; it is triggered by depolarization of cardiac muscle cells
 Diastole – the relaxation phase; immediately after depolarization is completed, the process reverses
itself, resulting in repolarization & a return to the resting state

LAB/DIAG TEST:

1. BLOOD CHEMISTRY
• Cardiac Isoenzymes

♥ Troponin T and I
 These are contractile proteins of the myofibril
 The cardiac isoforms are very specific for cardiac injury and are not present in serum from healthy
people
 Current guidelines from the American College of Cardiology Committee state that cardiac troponins
are the preferred markers for detecting myocardial cell injury
 Troponin I (cTnI) or T (cTnT) are the forms frequently assessed.
 Rises 2 - 6 hours after injury
 Peaks in 12 - 16 hours
 cTnI stays elevated for 5-10 days, cTnT for 5-14 days
♥ Creatine
Kinase (creatine phosphokinase)
 This enzyme is found in heart muscle (CK-MB),
skeletal muscle (CK-MM), and brain (CK-BB).
 Creatine kinase is increased in over 90% of
myocardial infarctions
 However, it can be increased in muscle trauma,
physical exertion, postoperatively, convulsions,
delirium tremens and other conditions.
 Time sequence after myocardial infarction
 begins to rise 4-6 hours
 peaks 24 hours
 returns to normal in 3-4 days

♥ Myoglobin
 Found in striated muscle
 Damage to skeletal or cardiac muscle releases myoglobin into circulation
  Have false positives with skeletal muscle injury and renal failure.
 Time sequence after myocardial infarction
 Rises fast (2 hours) after myocardial infarction
 Peaks at 6 - 8 hours
 Returns to normal in 20 - 36 hours

♥ Lactic Dehydrogenase
 This enzyme is no longer used to diagnose myocardial infarction
 Elevates after 24-48 hours

2. LIPID PROFILE:
• A group of tests that are often ordered together to determine risk of coronary heart disease
• They are tests that have been shown to be good indicators of whether someone is likely to have a heart attack
or stroke caused by blockage of blood vessels or hardening of the arteries (atherosclerois)
• The lipid profile typically includes:

Total Cholesterol Less than 200 mg/dL desirable

High density lipoprotein (HDL)
30 - 75 mg/dL
- good cholesterol
Low density lipoprotein (LDL)
Less than 130 mg/dL desirable
- bad cholesterol
Triglycerides (Male) Greater than 40 - 170 mg/dL
Triglycerides (Female) Greater than 35 - 135 mg/dL

3. HEMATOLOGIC STUDIES
• CBC
• Coagulation Time
• Prothrombin Time (PT)
• Partial Thromboplastin Time (PTT)
• ESR

4. ELECTRO CARDIOGRAM (ECG) – gives a graphic picture of your heart

5. STRESS TEST:
• Could be exercise (treadmill or bicycle), or chemical
(Persantine, dobutamine)
• Stress testing provides the doctor with information about
how the heart works during physical stress
• During a stress test, you exercise (walk or run on a
treadmill or pedal a bicycle) or are given a medicine to
make your heart work harder while heart tests are
performed
• During these tests, your heart is monitored using images or
through dime-sized electrodes attached to your chest,
arms, or legs. You may be asked to breathe into a
special tube during the test. This will allow your doctor to
see how well you’re breathing.

6. ECHOCARDIOGRAM:
• Non-invasive recording of the cardiac structures using an ultrasound
7. PHONOCARDIOGRAM – noninvasive device to amplify & record heart sounds and murmurs

8. CARDIAC CATHETERIZATION
• Invasive but most definitive test for diagnosis of
cardiac disease
• Purpose:
o To measure intracardic pressures & oxygen
levels in various parts of the heart
o With injection of a dye, allows visualization of
the heart chambers, blood vessels & course of
blood flow (angiography)
• Procedure:
 Right-Sided Catheterization
 The catheter is inserted into an antecubital
vein & advanced into the vena cava, right
atrium, & right ventricle with further
insertion into the pulmonary artery
 Left-Sided Catheterization
 The catheter is inserted into a brachial or
femoral artery; the catheter is passed
retrograde up the aorta & into the left
ventricle
• Pretest Nsg. Care:
 Confirm that informed consent has been signed
 Ask about allergies particularly to iodine if dye
is being used
 Keep client NPO for 8-12 hours prior to test
 Take baseline VS & monitor peripheral pulses
 Inform client that a feeling of warmth &
fluttering sensation as catheter is passed is common
• Posttest Nsg. Care:
 Assess circulation to the extremity used for catheter insertion
 Post-procedure Position: Maintain the patient in a supine position for a
minimum of 4 hours – this prevents hip flexion thereby limiting injury & promoting healing of the
catheter insertion site; HOB should be elevated but it should not exceed 20degrees
 Check peripheral pulses, color, sensation of affected extremity every 15 minutes for 4 hours
 If protocol requires, keep affected extremity straight for approximately 8 hours
 Observe catheter insertion for swelling & bleeding; a sandbag or pressure dressing may be placed over
insertion site
 Assess VS & report significant changes from baseline

9. AORTOGRAPHY
• Injection of a radiopaque contrast medium into the aorta to visualize the aorta, valve
leaflets & major vessels on a movie film
• Purpose: To determine & diagnose aortic valve incompetence, aneurysms
of the ascending aorta, abnormalities of major branches of the aorta
• PreTest & PostTest Nsg Care similar to Cardiac Catheterization
10. CORONARY ARTERIOGRAPHY
• Visualization of coronary arteries by injection of radiopaque contrast dye &
recording on a movie film
• Purpose: To evaluate heart disease & angina, location of areas of infarction &
extent of lesions, ruling out coronary artery disease in clients with myocardial
disease
• Nursing Care similar to Cardiac Catheterization

11. CENTRAL VENOUS PRESSURE (CVP)

• Obtained by inserting a catheter into the external jugular,
antecubital or femoral vein & threading it into the vena cava
• The catheter is attached to an IV infusion & water manometer by a
three way stopcock
• Purposes:
 Reveals right atrial pressure, reflecting alterations in the right
ventricular pressure
 Provides information concerning blood volume & adequacy of
central venous return
 Provides IV route for drawing blood samples, administering
fluids or medication, & possibly inserting a pacing catheter
• Normal Range: 4-10 cm H20; elevation indicates hypervolemia &
decreased level indicates hypovolemia
• Nursing Care:
 Ensure client is relaxed
 Maintain zero point of manometer always at the level of right
atrium (midaxillary line)
 Determine patency of catheter by opening IV line
 Turn stopcock to allow IV solution to run into manometer to a level of 10-20 cm above expected pressure
reading
 Turn stopcock to allow IV solution to flow from manometer into catheter; fluid level in manometer
fluctuates with respiration; where water flow stops – that is the CVP reading
 Stop ventilatory assistance during measurement of CVP
 After VP reading, return stopcock to IV infusion position (KVO rate)