Medical-Surgical Nursing Cardiopulmonary System Anatomy of the Heart

Coverings Pericardium a. fibrous pericardium b. serous Layers 1. 2. 3. Epicardium (visceral pericardium) -protects heart Myocardium cardiac muscle Endocardium epithelial/ connective/ fibers Muscular, pumping organ of the body Left mediastinum Weigh 300 400 grams Resembles a closed fist Covered by serous membrane pericardium

Four chambers A. Upper chambers -Collects blood 1. right atria 2. left atria B. Lower chambers -pumps blood from heart 1. right ventricle 2. left ventricle Arteries carry blood away from heart Veins blood toward heart Valves A. AV valves 1. Tricuspid right atrium 2. Bicuspid or mitral - left atrium Semilunar valves 1. Pulmonary semilunar (pulmonary trunk) 2. Aortic semilunar (aortic arch)

B.

Passage of Blood Through the Heart Blood follows this sequence through the heart: superior and inferior vena cava right atrium tricuspid valve right ventricle pulmonary semilunar valve pulmonary trunk and arteries to the lungs pulmonary veins leaving the lungs left atrium bicuspid valve left ventricle aortic semilunar valve aorta to the body. Blood supply to the heart Arterial supply The heart is supplied with arterial blood by the right and left coronary arteries, which branch from the aorta immediately distal to the aortic valve The coronary arteries receive about 5% of the blood pumped from the heart, although the heart comprises a small proportion of body weight This large blood supply, especially to the left ventricle, highlights the importance of the heart to body function The coronary arteries traverse the heart, eventually forming a vast network of capillaries Venous drainage Most of venous blood is collected into several small veins that join to form coronary sinus, which opens into right atrium

The remainder passes directly into the heart chambers through little venous channels

CARDIAC CYCLE
1. sequence of events that occur when the heart beats There are two phases of this cycle: Diastole - Ventricles are relaxed Systole - Ventricles contract Heart at rest Blood flows from large veins into atria Passive flow from atria into ventricles Atria (R & L) contract simultaneously Blood forced into ventricles Ventricles (R & L) contract simultaneously Atrioventricular valves close lubb sound Blood forced into large arteries Ventricles relax Semilunar valves close dub sound Heart at rest

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Heart valves Valves are flap-like structures that allow blood to flow in one direction The heart has two kinds of valves, atrioventricular and semilunar valves

Conducting system of Heart SA node

Acting as the heart's natural pacemaker, the SA node "fires" at regular intervals to cause the heart of beat with a rhythm of about 60 to 70 beats per minute for a healthy, resting heart The electrical impulse from the SA node triggers a sequence of electrical events in the heart to control the orderly sequence of muscle contractions that pump the blood out of the heart The AV node (AV stands for atrioventricular) is an electrical relay station between the atria (the upper) and the ventricles (the lower chambers of the heart) Electrical signals from the atria must pass through the AV node to reach the ventricles

AV node

AV node (bundle of his)

The bundle of His is located in the proximal interventicular septum It emerges from the AV node to begin the conduction of the impulse from the AV node to the ventricles

Purkinje fibers
Purkinje fibers are heart muscle tissues that are specialized to conduct electrical impulses to ventricular cells, which induce the lower chambers of the heart to contract Impulses from the upper chambers of the heart are relayed by this node to large bundles of Purkinje fibers referred to as the Bundle of His These bundles branch into smaller elements and eventually form terminal ends that burrow into left and right ventricular chamber muscles As the impulse is passed to the ventricles, the muscles contract and pump blood The contraction caused by the specialized fibers begins from the bottom of the ventricles and move upwards so that the blood leaves the lower chambers through the pulmonary arteries and the aorta

Electrocardiography Cardiac Output

CO is the amount of blood pumped by each ventricle in one minute CO is the product of heart rate (HR) and stroke volume (SV) HR is the number of heart beats per minute SV is the amount of blood pumped out by a ventricle with each beat

Regulation of Stroke Volume

SV = end diastolic volume (EDV) minus end systolic volume (ESV) EDV = amount of blood collected in a ventricle during diastole ESV = amount of blood remaining in a ventricle after contraction

Blood Vessels
Functions: Distribution of blood Exchange of materials with tissues Return of blood to the heart Structure:

Most have the same basic structure: 3 layers surrounding a hollow lumen

Arteries and veins are composed of three tunics: 1. tunica interna 2. tunica media 3. tunica externa Tunica Intima innermost smooth layer simple squamous epithelium continuous with the endocardium present in all vessels Tunica Media layer of smooth muscle - circular arrangement contains elastin supplied by sympathetic division of the ANS depending on bodys needs lumen is narrowed (vasoconstriction) or widened (vasodilation) Tunica Externa (Adventitia) thin layer of CT elastic & collagen fibres

Vessels Types
1. 2. 3. Arteries carry blood away from the heart Veins carry blood towards the heart Capillaries the most important part of the vascular system; site of exchange of materials

Disorders of the Cardiopulmonary System ATHEROSCLEROSIS

- condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol
-commonly referred to as a hardening or furring of the arteries. It is caused by the formation of multiple plaques within the arteries

Predisposing Factor 1. Sex male 2. Black race 3. Hyperlipidemia 4. Smoking 5. HPN 6. DM 7. Oral contraceptive- prolonged use 8. Sedentary lifestyle 9. Obesity 10. Hypothyroidism Signs & Symptoms 1. Chest pain 2. Dyspnea 3. Tachycardia 4. Palpitations 5. Diaphoresis Treatment P percutaneous T tansluminar C coronary A angioplasty Objective: 1. To revascularize the myocardium 2. To prevent angina 3. Increase survival rate PTCA done to pt. with single occluded vessel CABAG-for Multiple occluded vessels is CABAG C coronary A arterial B bypass A and G graft surgery Nsg Mgt Before CABAG 1. Deep breathing cough exercises 2. Use of incentive spirometer 3. Leg exercises

ANGINA PECTORIS
- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT nitroglycerin, resulting from myocardial ischemia Predisposing Factor 1. sex male 2. black raise 3. hyperlipidemia 4. smoking 5. HPN 6. DM 7. oral contraceptive prolonged 8. sedentary lifestyle 9. obesity 10.hypothyroidism

Precipitating factors 4 Es 1. Excessive physical exertion 2. Exposure to cold environment - Vasoconstriction 3. Extreme emotional response 4. Excessive intake of food saturated fats. Signs & Symptoms 1. Initial symptoms Levines sign hand clutching of chest Chest pain sharp, stabbing excruciating pain. Location substernal -radiates back, shoulders, axilla, arms & jaw muscles -relieve by rest or NGT 2. Dyspnea 3. Tachycardia 4. Palpitation 6.diaphoresis Diagnosis 1.History taking & PE 2. ECG ST segment depression 3. Stress test treadmill = abnormal ECG 4. Serum cholesterol & uric acid - increase Nursing Management 1.) Enforce Complete Bed Rest 2.) Administer medications as ordered NTG small doses venodilator Large dose vasodilator 1st dose NTG give 3 5 min 2nd dose NTG 3 5 min 3rd & last dose 3 5 min Still painful after 3rd dose notify the phycisian, It may be a sign of Myocardial Infaction Medications: A. NTG- Nsg Mgt: 1. Keep in a dry place. Avoid moisture & heat, may inactivate the drug 2. Monitor S/E: a. orthostatic hypotension decrease BP b. transient headache c. dizziness 3. Rise slowly from sitting position 4. Assist in ambulation. 5. If giving NTG via patch: a. avoid placing it near hairy areas because it will decrease drug absorption b. avoid rotating transdermal patches it will decrease drug absorption c. avoid placing near microwave oven or during defibrillation it will burn pt. due aluminum foil in patch B. Beta blockers propanolol C. ACE inhibitors captopril D. Ca antagonist - nefedipine 3.) Administer O2 inhalation 4.) Semi-fowler 5.) Diet- Decrease Na and saturated fats 6.) Monitor VS, I&O, ECG 7.) Health Teaching a. Avoid precipitating factors 4 Es b. Prevent complications MI c. Take meds before physical exertion-to achieve maximum therapeutic effect of drug d. Importance of follow-up care

MYOCARDIAL INFARCTION(MI)

-hear attack terminal stage of CAD -Characterized by necrosis & scarring due to permanent mal-occlusion Types 1. 2.

Trasmural MI most dangerous MI Mal-occlusion of both R&L coronary artery Sub-endocardial MI mal-occlusion of either R & L coronary artery

Most critical period upon diagnosis of MI 48 to 72h Because majority of pt suffers from PVC premature ventricular contraction Predisposing factors sex male black raise hyperlipidemia smoking HPN DM oral contraceptive prolong ed 8. sedentary lifestyle 9. obesity 10. hypothyroidism 1. 2. 3. 4. 5. 6. 7. Signs & symptoms 1. chest pain excruciating, vice like, visceral pain located substernal or precodial area (rare) - radiates back, arm, shoulders, axilla, jaw & abd muscles. - not usually relived by rest r NTG 2. dyspnea 3. erthermia 4. initial increase in BP 5. mild restlessness & apprehensions 6. occasional findings a.) split S1 & S2 b.) pericardial friction rub c.) rales /crackles d.) S4 (atrial gallop) Diagnostic Exam 1. cardiac enzymes a.) CPK MB Creatinine Phosphokinase b.) LDH lactic acid dehydrogenase c.) SGPT (ALT) Serum Glutanic Pyruvate Transaminase- increased d.) SGOT (AST) Serum Glutamic Oxalo-acetic - increased 2. Troponin test increase 3. ECG tracing ST segment increase, widening or QRS complexes means arrhythmia in MI indicating PVC 4. serum cholesterol & uric acid - increase 5. CBC increase WBC

Nursing Management 1. Narcotic analgesics Morphine SO4 to induce vasodilation & decrease levels of anxiety 2. Administer O2 inhalation low inflow (CHF-increase inflow) 3. Enforce Complete Bed Rest without BP a.) Prepare commode at bedside 4. Avoid valsalva maneuver 5. Semi fowler 6. General liquid to soft diet decrease Na, saturated fat, caffeine 7. Monitor VS, I&O & ECG tracings 8. Take 20 30 ml/week wine, brandy/whisky to induce vasodilation 9. Assist in surgical; CABAG 10. Provide pt. Health Teaching a.) Avoid modifiable risk factors b.) Prevent complications: 1. Arrhythmias PVC 2. Shock cardiogenic shock. Late signs of cardiogenic shock in MI oliguria 3. Thrombophlebitis - deep vein 4. CHF left sided 5. Dresslers syndrome post MI syndrome -Resistant to medications -Administer 150,000 450,000 units of streptokinase c.) Strict compliance to medications 1. Vasodilators a. NTG b. Isordil 2. Antiarrythmic a. Lydocaine b. Brithylium 3. Beta-blockers lol a. Propanolol (inderal) 4. ACE inhibitors - pril a. Captopril (enalapril) 5. Ca antagonist a. Nifedipine 6. Thrombolitics or fibrinolytics to dissolve clots/ thrombus

d.) Resume ADL sex/ activity after 4 to 6 weeks

1.)Sex as an appetizer rather then dessert Before meals not after, due after meals increase metabolism heart is pumping hard after meals. 2.) Position non-weight bearing position When to resume sex/ act: When pt can already use staircase, then he can resume sex. e.) Diet decrease Na, Saturated fats, and caffeine f.) Follow up care

CONGESTIVE HEART FAILURE(CHF)

- Inability of heart to pump blood towards systemic circulation - Backflow -CHF can be Left-sided or Right-sided -Left-sided CHF can lead to Right-sided CHF, but Right cannot lead to Left -Lasix is given to both types of CHF -CHF is the inability of the heart to pump blood towards systemic circulation RIGHT-SIDED CHF the #1 cause is TRICUSPID VALVE STENOSIS LEFT-SIDED CHF the #1 cause is MITRAL VALVE STENOSIS

Left sided heart failure

Predisposing factors -Can be caused by Rheumatic Heart Disease: Tonsillitis strep bacteria migrate to mitral valve RHEUMATIC HEART DISEASE mitral stenosis LSHF Complication 1. Right Sided-CHF 2. Aging degeneration / calcification of mitral valve 3. Ischemic heart disease 4. HPN, MI, Aortic stenosis Signs and Symptoms Pulmonary congestion/ Edema 1. Dyspnea 2. Orthopnea 3. Paroxysmal nocturnal dysnea 4. Productive cough with blood tinged sputum 5. Frothy salivation (from lungs) 6. Cyanosis 7. Rales/ crackles due to fluid 8. Bronchial wheezing 9. PMI(Point of Maximal Implant) is displaced laterally due to cardiomegaly 10. Pulsus alternons weak-strong pulse 11. Anorexia & general body malaise 12. S3 extra heart sound (Ventricular gallop) Diagnostic 1. Chest Xray cardiomegaly 2. PAP Pulmonary Arterial Pressure PCWP Pulmonary CapillaryWedge Pressure 3. Echocardiography reveals enlarged heart chamber or cardiomayopathy 4. ABG PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis

Right sided HF
Predisposing factor 1. 90% - tricuspid stenosis 2. COPD 3. Pulmonary embolism 4. Pulmonic stenosis 5. Left sided heart failure Signs and Symptoms 1. Venous congestion 2. Neck or jugular vein distension

3. 4. 5. 6. 7. 8. 9. 10.

Pitting edema Ascites Wt gain Hepatomegalo/ splenomegaly Jaundice Pruritus Esophageal varies Anorexia, gen body malaise

Diagnosis 1. CXR cardiomegaly 2. CVP measures the pressure at R atrium Normal: 4 to 10 cm of water Increase CVP > 10 hypervolemia Decrease CVP < 4 hypovolemia Flat on bed position of pt. when giving CVP Position during CVP insertion Trendelenburg to prevent pulmonary embolism & promote ventricular filling 3. Echocardiography enlarged heart chamber / cardiomyopathy 4.Liver enzyme Increase SGPT ( ALT) Increase SGOT AST Nursing Management 1.Administer medications as ordered Treatment for LSHF: M morphine SO4 to induce vasodilatation A aminophylline & decrease anxiety D digitalis (digoxin) D - diuretics O - oxygen G - gases a.) Cardiac glycosides Increase myocardial = increase CO Digoxin (Lanoxin). Antidote: digivine Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure. b.) Loop diuretics: Lasix takes effect within 10-15 min. Max = 6 hrs c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety e.) Vasodilators NTG f.) Anti-arrythmics Lidocaine 2. Administer O2 inhalation @ 3 -4L/min via nasal cannula 3. High fowlers 4. Restrict Na 5. Provide meticulous skin care 6. Weigh pt. daily. Assess for pitting edema. Measure abdominal girth daily & notify MD 7. Monitor V/S, I&O, breath sounds 8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins to promote decrease venous return 9. Diet decrease salt, fats & caffeine 10. Health Teachings Complications : 1. shock 2. Arrhythmia 3. Thrombophlebitis 4. MI 5. Cor Pulmonale RT ventricular hypertrophy b.) Dietary modifications c.) Adherence to meds

PERIPHERAL MUSCULAR DISEASE Thromboangiitis obliterates/ BUERGER DISEASE

- Acute inflammatory disorder affecting small to medium sized arteries & veins of lower extremities Predisposing factors: Male Smokers Signs and Symptoms 1. Intermittent claudication leg pain upon walking relieved by rest 2. Cold sensitivity & skin color changes 3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis 4. Tropic changes 5. Ulcerations 6. Gangrene formation Dianostic 1. Oscillometry decrease peripheral pulse volume 2. Doppler UTZ decrease blood flow to affected extremities 3. Angiography reveals site & extent of mal-occlusion Nursing Management 1. Encourage a slow progression of physical activity a.) Walk 3 -4 x / day b.) Out of bed 2 3 x a / day 2. Administer medications as ordered a.) Analgesic b.) Vasodilator c.) Anticoagulant 3. Foot care mgt. like DM a.) Avoid walking barefoot b.) Cut toe nails straight c.) Apply lanolin lotion prevent skin breakdown d.) Avoid wearing constrictive garments 4. Avoid smoking & exposure to cold environment 5. Surgery: BKA (Below the knee amputation)

REYNAUDS PHENOMENON
acute episodes of arterial spasm affecting digits of hands & fingers Predisposing factors 1. Female, 40 yrs 2. Smoking 3. Collagen disease a. SLE pathognomonic sign butterfly rash on face 1. Chipmunk face bulimia nervosa 2. Cherry red skin carbon monoxide poisoning 3. Spider angioma liver cirrhosis 4. Caput medusae leg & trunk umbilicus- Liver cirrhosis 5. Lion face leprosy b. Rheumatoid arthritis 4. Direct hand trauma piano playing, excessive typing, operating chainsaw

Signs and Symptoms

1. 2.

Intermittent claudication - leg pain upon walking - Relieved by rest Cold sensitivity

Nursing Management a. Analgesics b. Vasodilators c. Encourage to wear gloves especially when opening a refrigerator d. Avoid smoking & exposure to cold environment