Structure and Function of the Heart

Function and Location of the Heart The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest. Structure of the Heart The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point and about 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it to move as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle. Chambers of the Heart The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and a bottom chamber. The two top chambers are known as the left and right atria (singular: atrium). The atria

receive blood from different sources. The left atrium receives blood from the lungs and the right atrium receives blood from the rest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles pump blood out to different parts of the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. The ventricles have much thicker walls than the atria which allows them to perform more work by pumping out blood to the whole body. Blood Vessels Blood Vessel are tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries are blood vessels which carry blood from the heart to the body. There are also microscopic blood vessels which connect arteries and veins together called capillaries. There are a few main blood vessels which connect to different chambers of the heart. The aorta is the largest artery in our body. The left ventricle pumps blood into the aorta which

then carries it to the rest of the body through smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries which take the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain into the inferior vena cava (IVC) or the superior vena cava (SVC). These two large veins then take the blood from the rest of the body into the right atrium. Valves Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates which prevent blood from flowing in the wrong direction. They are found in a number of places. Valves between the atria and ventricles are known as the right and left atrioventricular valves, otherwise known as the tricuspid and mitral valves respectively. Valves between the ventricles and the great arteries are known as thesemilunar valves. The aortic valve is found at the base of the aorta, while

the pulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body. However, there are no valves found in any of the other arteries besides the aorta and pulmonary trunk. What is the Cardiovascular System The cardiovascular system refers to the heart, blood vessels and the blood. Blood contains oxygen and other nutrients which your body needs to survive. The body takes these essential nutrients from the blood. At the same time, the body dumps waste products like carbon dioxide, back into the blood, so they can be removed. The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive. Veins deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as the body has unloaded it back into the blood). All the veins drain into the superior and inferior vena cava which then

drain into the right atrium. The right atrium pumps blood into the right ventricle. Then the right ventricle pumps blood to the pulmonary trunk, through the pulmonary arteries and into the lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen which the body can use. From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta which then distributes it to the rest of the body through other arteries. The main arteries which branch off the aorta and take blood to specific parts of

the body are: Carotid arteries, which take blood to the neck and head Coronary arteries, which provide blood supply to the heart itself Hepatic artery, which takes blood to the liver with branches going to the stomach Mesenteric artery, which takes blood to the intestines Renal arteries, which takes blood to the kidneys Femoral arteries, which take blood to the legs

The body is then able to use the oxygen in the blood to carry out its normal functions. This blood will again return back to the heart through the veins and the cycle continues.

What is the Cardiac Cycle

The cardiac cycle is the sequence of events that occurs in one complete beat of the heart. The pumping phase of the cycle, also known as systole, occurs when heart muscle contracts. The filling phase, which is known asdiastole, occurs when heart muscle relaxes. At the beginning of the cardiac cycle, both atria and ventricles are in diastole. During this time, all

the chambers of the heart are relaxed and receive blood. The atrioventricular valves are open. Atrial systole follows this phase. During atrial systole, the left and right atria contract at the same time and push blood into the left and right ventricles, respectively. The next phase is ventricular systole. During ventricular systole, the left and right ventricles contract at the same time and pump blood into the aorta and pulmonary trunk, respectively. In ventricular systole, the atria are relaxed and receive blood. The atrioventricular valves close immediately after ventricular systole begins to stop blood going back into the atria. However, the semilunar valves are open during this phase to allow the blood to flow into the aorta and pulmonary trunk. Following this phase, the ventricles relax that is ventricular diastole occurs. The semilunar valves close to stop the blood from flowing back into the ventricles from the aorta and pulmonary trunk. The atria and ventricles once again are in diastole together and the cycle begins again.

Components of the Heartbeat

The adult heart beats around 70 to 80 times a minute at rest. When you listen to your heart with a stethoscope you can hear your heart beat. The sound is usually described as "lubb-dupp". The "lubb" also known as the first heart sound, is caused by the closure of the atrioventricular valves. The "dupp" sound is due to the closure of the semilunar valves when the ventricles relax (at the beginning of ventricular diastole). Abnormal heart sounds are known as murmurs. Murmurs may indicate a problem with the heart valves, but many types of murmur are no cause for concern. (For more information see: (see Valvular Heart Disease)
The Electrocardiogram

The heart has an inbuilt rhythm of contraction and relaxation. A small group of heart muscle cells called the pacemaker help achieve this. The pacemaker generates an electrical impulse which spreads over the atria, making them contract. This impulse then

spreads to the ventricles, causing them to contract. The electrical changes that spread through the heart can be detected at the surface of the body by an instrument called the electrocardiograph. Electrodes are placed in a number of positions over the chest and the electrical changes are recorded on moving graph paper as an electrocardiogram (ECG).
Effects of Aging on the Heart in Men and Women

As a part of the normal aging process a number of

changes occur to the cardiovascular system. Our heart rate slows down because the time between heartbeats increases as we age. This is one of the main reasons why the heart is unable to pump out more blood during exercise when we become old. The amount of blood the heart pumps each minute can change as we age. It decreases slightly in older women. However, it does not change in healthy older men who have no heart disease. The reason for the difference between the sexes is not fully understood. As we age, our blood pressure falls much more on standing from the sitting position compared to when we are younger. This phenomenon is known as postural hypotension. This

explains why elderly people are more likely to feel dizzy or to fall when they stand up quickly from a resting position.

Hypertension

(high blood pressure) is a disease of vascular regulation resulting from malfunction of arterial pressure control mechanisms (central nervous system, rennin-angiotensinaldosterone system, extracellular fluid volume.) the cause is unknown, and there is no cure. The basic explanation is that blood pressure is elevated when there is increased cardiac output plus increased peripheral vascular resistance.
The two major types of hypertension are primary (essential) hypertension, in which diastrolic pressure is 90 mm Hg or higher and systolic pressure is 140 mm Hg or higher in absence of other causes of hypertension (approximately 95 % of patients); and Secondary hypertension,which results primarily from renal disease, endocrine disorders, and coarctation of the aorta. Either of these conditions may give rise to accelerated hypertension a medical emergency in which blood pressure elevates very rapidly to threaten one or more of the target organs: the brain, kidney, or the heart. Hypertension is one of the most prevalent chronic diseases for which treatment is available; however, most patients with hypertension are unaware, untreated, or inadequately treated. Risk factors for hypertension are age between 30 and 70; black; overweight; sleep apnea; family history; cigarette smoking; sedentary lifestyle; and diabetes mellitus. Because hypertension presents no over symptoms, it is termed the silent killer. The untreated disease may progress to retinopathy, renal failure, coronary artery disease, heart failure, and stroke. Hypertension in children is defined as the average systolic or diastolic blood pressure greater than or equal to the 95th percentile for age and sex with measurement on at lease three occasions. The incidence of hypertension in children is low, but it is increasingly being recognized in adolescents; and it may occur in neonates, infants, and young children with secondary causes.

Hypertension

refers to a state where a persons blood pressure remains at an elevated level at all times. This condition is formally known as arterial hypertension and is popularly called high blood pressure.
Two types of hypertension: 1. Primary Hypertension when a patients chronically elevated blood pressure does not have a specific medical cause that can be identified 2. Secondary Hypertension When high blood pressure is caused by other health conditions like tumors of the adrenal gland, kidney disease of other problems. Hypertension is a dangerous condition because it can lead to serious complications. Chronically elevated blood pressure increases the risk of developing heart failure, heart attacks, arterial

aneurysm and strokes. Many cases of chronic renal failure have been linked to high blood pressure. Signs and Symptoms: Undiagnosed high blood pressure can lead to many physical problems including damage to major organs over a period of time. The symptoms of hypertension, if ignored, can lead to deterioration in kidney / liver function and cardiac problems. Hypertension can also damage vision, cause strokes and more. Here are some of the common hypertension symptoms to be aware of.

Recurrent / persistent headaches Vision problems including blurring of vision Giddiness Convulsions Tremors in the hands or other body parts Walking difficulties (formally called ataxia)

INTRODUCTION Hypertension is one of the most common worldwide diseases afflicting humans. Because of the associated morbidity and mortality and the cost to society, hypertension is an important public health challenge. Over the past several decades, extensive research, widespread patient education, and a concerted effort on the part of health care professionals have led to decreased mortality and morbidity rates from the multiple organ damage arising from years of untreated hypertension. Hypertension is the most important modifiable risk factor for coronary heart disease (the leading cause of death in North America), stroke (the third leading cause),congestive heart failure, end-stage renal disease, and peripheral vascular disease. Therefore, health care professionals must not only identify and treat patients with hypertension but also promote a healthy lifestyle and preventive strategies to decrease the prevalence of hypertension in the general population. Pre-hypertension Systolic blood pressure (SBP) 120-139 or diastolic blood pressure(DBP) Stage I HTN SBP 140-159 or DBP 90-99 Stage II HTN SBP >160 or DBP >100 80-89

Hypertensive crises encompass a spectrum of clinical presentations where uncontrolled BPs leads to progressive or impending target organ dysfunction (TOD). The clinical distinction between hypertensive emergencies and hypertensive urgencies depends on the presence of acute TOD and not on the absolute level of the BP. Hypertensive emergencies represent severe HTN with acute impairment of an organ system (eg, central nervous system [CNS], cardiovascular, renal). In these conditions, the BP should be lowered aggressively over minutes to hours. Hypertensive urgency is defined as a severe elevation of BP, without evidence of progressive target organ dysfunction. These patients require BP control over several days to weeks. Causes The most common hypertensive urgency is a rapid unexplained rise in BP in a patient with chronic essential HTN. Other causes:

Renal parenchymal disease Chronic pyelonephritis, primary glomerulonephritis, tubulointerstitial nephritis (accounts for 80% of all secondary causes) Systemic disorders with renal involvement Systemic lupus erythematosus, systemic sclerosis, vasculitides Renovascular disease Atherosclerotic disease, fibromuscular dysplasia, polyarteritis nodosa Endocrine Pheochromocytoma, Cushing syndrome, primary hyperaldosteronism Drugs Cocaine, amphetamines, cyclosporin, clonidine withdrawal, phencyclidine, diet pills, oral contraceptive pills

Drug interactions Monoamine oxidase inhibitors with tricyclic antidepressants, antihistamines, or tyramine-containing food CNS CNS trauma or spinal cord disorders, such as Guillain-Barr syndrome Coarctation of the aorta Preeclampsia/eclampsia Postoperative hypertension

Physical Vitals

BP should be measured in both the supine position and the standing position (assess volume depletion). BP should also be measured in both arms (a significant difference suggests an aortic dissection).

ENT: The presence of new retinal hemorrhages, exudates, or papilledema suggests a hypertensive urgency. Cardiovascular Evaluate for the presence of heart failure.

Jugular venous distension Crackles Peripheral edema

Abdomen Abdominal masses or bruits CNS

Level of consciousness Visual fields Focal neurologic signs

Takayasu arteritis is a granulomatous vasculitis of unknown etiology that commonly affects the thoracic and abdominal aorta. It causes intimal fibroproliferation of the aorta, great vessels, pulmonary arteries, and renal arteries and results in segmental stenosis, occlusion, dilatation, and aneurysmal formation in these vessels. Takayasu arteritis is the only form of aortitis that causes stenosis and occlusion of the aorta. Takayasu disease has also been referred to as pulseless disease and aortic arch syndrome. During the acute inflammatory stage, Takayasu disease causes a low-grade temperature, tachycardia, pain adjacent to the inflamed arteries (eg, carotodynia), and easy fatigability in 50% of patients. Carotid and clavicular bruits, asymmetric upper-extremity blood pressures, hypertension, diminished or absent upper-extremity pulses, and ischemic symptoms can suggest the diagnosis ANATOMY & PHYSIOLOGY Central Nervous System Medulla Oblongata; relays motor and sensory impulses between other parts of the brain and the spinal cord. Reticular formation (also in pons, midbrain, and diencephalon) functions in

consciousness and arousal. Vital centers regulate heartbeat, breathing (together with pons) and blood vessel diameter. Hypothalamus; controls and intergrates activities of the autonomic nervous system and pituitary gland. Regulates emotional and behavioral patterns and circadian rhythms. Controls body temperature and regulates eating and drinking behavior. Helps maintain the waking state and establishes patterns of sleep. Produces the hormones oxytocin and antidiuretic hormone. Cardiovascular System Baroreceptor, pressure-sensitive sensory receptors, are located in the aorta, internal carotid arteries, and other large arteries in the neck and chest. They send impulses to the cardiovascular center in the medulla oblongata to help regulate blood pressure. The two most important baroreceptor reflexes are the carotid sinus reflex and the aortic reflex. Chemoreceptors, sensory receptors that monitor the xhemical composition of blood, are located close to the baroreceptors of the carotid sinus and the arch of the aorta in small structures called carotid bodies and aortic bodies, respectively. These chemoreceptors detect changes in blood level of O2, CO2, and H+. Renal System Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the kidneys decreases, juxtaglomerular cells in the kidneys secrete renin into the bloodstream. In sequence, renin and angiotensin converting enzyme (ACE) act on their substrates to produce the active hormone angiotensin II, which raises blood pressure in two ways. First, angiotensin II is a potent vasoconstrictor; it raises blood pressure by increasing systemic vascular resistance. Second, it stimulates secretion of aldosterone, which increases reabsorption of sodium ions and water by the kidneys. The water reabsorption increases total blood volume, which increases blood pressure. Antidiuretic hormone. ADH is produced by the hypothalamus and released from the posterior pituitary in response to dehydration or decreased blood volume. Among other actions, ADH causes vasoconstriction, which increases blood pressure. Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers blood pressure by causing vasodilation and by promoting the loss of salt and water in the urine, which reduces blood volume. NURSING ASSESSMENT Present Health History The present health history started 7 days prior to confinement at PCMC when the patient, experienced general body weakness, vomiting and elevated blood pressure. She was admitted at Duques Clinic for 3 days but no BP monitoring was done. After 3 days, she was transferred to Cabiao General Hospital. Chest x-ray was done and the result implies cardiomegaly. She stayed at the said institution for 2 days and was treated as a case of hypertension. The patient

was referred to Nueva Ecija Doctors last April 10, she had undergone ultrasound of her abdomen. She was given furosemide, nifedipine, mefenamic acid and ranitidine as her medication. Last April 12, 2007 at 12:55am she was admitted at the Philippine Childrens Medical Center with a diagnosis of Hypertensive Urgency secondary to Takayasu disease. Past Health History Prior to her hospitalization , she denies in having any record or medical history of being admitted due to trauma, accident and disease. She also denies having allergies to food and drugs. Family Health History The patient has family health history of hypertension on her mothers side. Demographic Data/Physical Assessment & General Appearance Review of Systems ? Psychosocial Being the second among three children, she considers herself as an active individual who is fond of interacting with other people. She considers herself as friendly even at home and at work. She excels in her subjects especially in Mathematics. ? Elimination Her elimination pattern has somehow deviated from her usual urine and stool elimination. Before her confinement, she usually urinates for 7 times a day and defecates at least 2 times per day. During her confinement, she now urinates 4 times a day and defecates once a day. According to her the variation from her elimination pattern is due to change in appetite and setting. ? Rest & Activity A typical day to her would be waking up at around 7:00 am to eat breakfast and play with her siblings. She had is fond of playing in their neighborhood and running around their house. Her usual sleeping hours is at 8:00 pm. During her confinement, she was not able to rest and have enough sleep as well. During her leisure time before confinement, she loves to watch television. ? Safety She usually stays at home and around their vicinity when playing. There is no physical threat for her safety. ? Oxygenation According to her, before and during her confinement she had no difficulty in breathing and ventilation. ? Nutrition According to her mother, she has a good appetite. She prefers to eat fish and vegetables rather than meat. She also adds that her daughter prefers to drink water. PATHOPHYSIOLOGY LABORATORY DIAGNOSIS

MEDICAL & SURGICAL MANAGEMENT There are three clinical indications for selecting a patient with a hemodynamically significant renal artery stenosis (RAS) for treatment. The first is hypertension that is poorly controlled on adequate (two or three drugs) medical therapy, or in a patient intolerant of hypertensive medications. The second is renal insufficiency, and the third is a cardiac disturbance syndrome, such as flash pulmonary edema. The treating physician should have a high clinical suspicion that the target RAS is causally related to the clinical symptoms. The procedural risks, potential benefits, and alternative therapies must be considered for each patient. Generally, a RAS of <50% does not require revascularization, while a symptomatic patient with a stenosis ?70% generally merits revascularization. Absolute criteria for determining lesion severity have not been established; however, a systolic translesional pressure gradient of ?20 mm Hg or a mean gradient of ?10 mm Hg is generally accepted as representing significant renal artery obstruction in symptomatic patients. Stents are superior to balloons for both procedural success and long-term patency, due to scaffolding of the arterial lumen. The single, randomized, controlled trial comparing stents to balloons in renovascular hypertension demonstrated procedural superiority, better patency rates, and cost-effectiveness for primary stent placement. Despite a uniformly high (?95%) technical success rate for renal artery stent placement, very few patients will be cured of hypertension. However, the majority of hypertensive patients will benefit by improved blood pressure control and/or the need for fewer medications. Patients with the highest pretreatment systolic blood pressures have the greatest decrease in systolic pressure. A multivariate logistic regression analysis demonstrated that bilateral RAS and mean arterial pressure >110 mm Hg predicted a better blood pressure response following stent placement. Studies comparing the results in elderly (?75 years) versus younger (<75 years) patients or in females versus males have failed to show any difference in response to renal stent placement. The suggestion that a high level of resistance in the segmental renal arteries (resistance index ?80), determined by noninvasive Doppler measurement, predicted a poor response to revascularization has been challenged by more recent data that suggested that patients with increased resistance respond favorably to renal intervention. The benefits of renal stent placement include reperfusion of the ischemic kidney(s), resulting in a reduction in the stimulus to renin production, which decreases angiotensin and aldosterone production, thereby decreasing peripheral arterial vasoconstriction and intravascular volume. Improving renal perfusion enhances glomerular filtration, thus natriuresis. Finally, in patients with a solitary kidney or bilateral RAS, the administration of angiotensin antagonists is facilitated by revascularization.