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o Semilunar valves – resemble portion of the moon, prevent blood from flowing
back into the ventricles after the heart contracts.
Pulmonic valve – valve between the right ventricle and pulmonary artery
Aortic valve – between the left ventricle and aorta
Myocardial Blood Supply
The left coronary artery branches out into the left anterior descending (LAD) artery
and the circumflex artery.
o The LAD artery supplies blood to the anterior wall of the ventricle, the anterior
ventricular septum, and the bundle branches.
o The circumflex artery provides blood to the lateral and posterior portions of the left
ventricle.
The right coronary artery (RCA) fills the groove between the atria and ventricles and
gives rise to the right marginal artery, ending as the posterior descending artery.
o The RCA sends blood to the sinus and atrioventricular nodes to the right atrium.
o The posterior descending artery supplies the posterior and inferior wall of the left
ventricle and the posterior portion of the right ventricle.
Coronary arteries receive blood primarily during ventricular relaxation (diastole)
Blood is pumped out to the systemic circulation during contraction of the ventricles
(systole)
Circulation
Inferior and superior vena cava to right atrium
Through tricuspid valve to right ventricle
Through pulmonic valve to pulmonary artery
To lungs
Through pulmonary veins to left atrium
Through mitral valve to left ventricle
Through aortic valve to aorta
To systemic circulation
Electrical Conduction
The heart contains specialized muscle fibers that generate and conduct their own electrical
impulses spontaneously
The following make up the system that conducts electrical impulses and coordinates
chamber contractions:
o SA Node (Sinoatrial) – is an area of nerve tissue located in the posterior wall of
the right atrium. It is also called the pacemaker of the heart. It produces 62 -100
impulses per minute, the average of which is around 72 impulses.
o AV Node (AV Junction) – located in the lower aspect of the atrial septum. It can
be a secondary cardiac pacemaker, but normally receives electrical impulses from
the SA Node and it is the only pathway for conducting impulses from the atria to
the ventricles. The slow rate of action potential conduction in the AV node allows
the atria to complete their contraction before action potentials are delivered to the
ventricles.
o Bundle of His – it is the intraventricular septum, which is relatively short,
branching into right and left segments.
o Purkinje Fibers – are diffuse network of conducing strands beneath the
ventricular endocardium; they rapidly spread the wave of depolarization through
the ventricles.
Impulses follow a right-to-left, top-to-bottom path
A normal electrical impulse is initiated at the SA node, the heart’s intrinsic pacemaker.
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Once generated, the normal impulse must move forward through the conduction system to
the ventricles.
Numerous events occur almost simultaneously in the following order after the initiation of
the impulse at the SA node.
o Atrial depolarization
o Atrial contraction
o Impulse transmission to the AV node
o Impulse transmission to the bundle of His, bundle branches, and Purkinje fibers
o Ventricular depolarization
o Ventricular contraction
o Ventricular repolarization.
Cardiac Function
Cardiac Output (CO) – total amount of blood ejected per minute (4-8 L / min; ave: 5L)
Stroke Volume (SV) – amount of blood ejected with each beat (ave: 65 – 70 mL)
Cardiac output equals stroke volume times heart rate (HR)
Cardiac Output = Stoke Volume x Heart Rate
Alterations in cardiac output affect every body system
Ejection fraction is the percent of left ventricular end-diastolic volume ejected during
systole (60 to 70%)
Cardiac Cycle
It refers to the contraction (systole) and relaxation (diastole) of both atria and both
ventricles.
The contraction of the left ventricle can be felt as a wave-like impulse (pulse) in the
peripheral arteries.
Starling’s Law – the greater the stretch of the myocardium as the ventricles fill with
blood, the stronger is the ventricular contraction.
Heart Rate
The normal heart rate is 60 – 100 beats per minute.
Sinus tachycardia is a rate of more than 100 BPM
Sinus bradycardia is a rate of lower than 60 BPM
Intrinsic heart rate is 90 BPM.
At rest, the heart rate of 70 BPM reflects the dominant control by the parasympathetic
nervous system.
Arterial Pressure
It is the pressure of blood against the arterial walls.
Systolic pressure is the maximum pressure of the blood exerted against the artery walls
when the heart contracts (normally 100 – 140 mm Hg)
Diastolic pressure is the force of blood exerted against the artery walls during the
heart’s relaxation (or filling) phase (normally 60 -90 mm Hg).
Blood pressure is expressed as systolic / diastolic pressure (e.g. 120 /80)
Blood Vessels
Arteries are three-layered vessels that carry oxygenated blood from the heart to the
tissues. Arteries have thicker walls but are smaller in diameter.
o Tunica Adventitia – the outer layer, consists of the connective tissue
o Tunica Media – middle layer, consists of smooth muscle
o Tunica Intima – the inner layer, composed of endothelial cells
Arterioles are small resistance vessels that feed into capillaries
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Capillaries join arterioles to venules (larger, lower-pressured vessels that arterioles),
where nutrients and wastes are exchanged.
Venules join capillaries to veins
Veins are large-capacity, low-pressure vessels that return unoxygenated blood to the
heart. Veins have thinner walls than arteries because venous pressure is lower than
arterial pressure. Despite being having thinner walls, veins, in turn, have larger diameters
than those of arteries.
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Electrocardiography (ECG)
Non-invasive test
Graphical representation of the heart’s electrical activity
Nursing Interventions:
o Determine the patient’s ability to lie still
o Reassure the patient that electrical shock won’t occur
o Interpret ECG for changes
Ambulatory Electrocardiography (Holter monitoring)
Non-invasive test
Records the heart’s electrical activity and cardiac events for 24 hours
Nursing Interventions:
o Advise the patient on activity limitations while wearing monitor:
Instruct the patient not to bathe, shower, operate machinery, or use a
microwave oven or an electric shaver while wearing the monitor.
o Instruct the patient to keep an activity diary.
Cardiac Catheterization
Invasive, fluoroscopic procedure
Examines intracardiac structures, pressures, oxygenation, and cardiac output
Nursing Intervention:
o Before the procedure:
Withhold the patient’s food and fluids after midnight.
Take baseline vital signs and palpate peripheral pulses.
Place obtained written informed consent in the patient’s chart.
Inform the patient about possible nausea, chest pain, flushing of the face, or
throat irritation form the injection of radiopaque dyes.
Note the patient’s allergies to seafood, iodine or radiopaque dyes
before testing
Shave and scrub the insertion site as ordered
Mark peripheral pulses with an “X”
Administer sedation as prescribed
Remove all jewelry, and prosthetic devises.
Ensure patent I.V. access
o After the procedure:
Monitor vital signs, peripheral pulses, and insertion site for bleeding
Maintain a pressure dressing and bed rest for 4 to 8 hours, or as ordered.
Increase fluid intake unless contraindicated.
Allay the patient’s anxiety.
Monitor for complaints of chest pain, a possible sign of myocardial
infarction (MI) – a serious complication of cardiac catheterization –
and report immediately!
Keep affected leg extended
Assess peripheral pulses in both legs and compare to baseline
Monitor urinary output
Monitor for delayed reaction for radiopaque dye
Coronary Arteriography
Invasive, fluoroscopic procedure
Examination of coronary arteries
Nursing Interventions:
o Before the procedure:
Note the patient’s allergies to iodine, seafood, or radiopaque dyes
Monitor the patient’s vital signs
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Allay the patient’s anxiety.
Inform the patient about possible flushing of the face or throat irritation
from the injection.
o After the procedure:
Check the insertion site for bleeding
Assess peripheral pulses
Maintain a pressure dressing at bed rest
Digital subtraction angiography
Invasive procedure using a computer system and fluoroscopy with an image intensifier
Allows for complete visualization of the arterial blood supply to a specific area especially
the carotid and cerebral arteries
Nursing Interventions:
o Before the procedure:
Place obtained written informed consent in the patient’s chart
Monitor the patient’s vital signs
Remove all jewelry in the are to be imaged
Perform a baseline neurologic examination before cerebral
angiography
Administer sedation, as ordered
o After the procedure:
Check the insertion site for bleeding
Instruct the patient to drink at least 1 L of fluid
Monitor delayed reaction to radiopaque dye
Echocardiography
Non-invasive examination of the heart
Uses echoes from sound waves to visualize intracellular cardiac structures and direction of
blood flow.
Nursing Interventions:
o Determine the patient’s ability to lie still
o Explain the procedure
Exercise (Stress) Testing
Non-invasive test of the heart
Study of the heart’s electrical activity and ischemic events during prescribed levels of
exercise
Nursing Interventions:
o Withhold food and fluids, especially those that contain caffeine, for 1 hour
before the test
o Instruct the patient to wear loose-fitting clothing and supportive shoes
o Explain the procedure
Nurclear Cardiology
Visual examination of the heart using radioisotopes
Imaging of myocardial perfusion and contractility after I.V. injection of isotopes
Nursing Interventions:
o Explain the procedure
o Allay the patient’s anxiety
o Determine the patient’s ability to lie still during the procedure
Hemodynamic Monitoring (Single procedure or continuous monitoring)
Invasive procedure involving balloon-tipped, flow-directed catheter placed in pulmonary
artery (pulmonary artery catheter)
Allows for examination of intracardiac pressures and cardiac output
Nursing Interventions:
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o Before the procedure:
Place the obtained written informed consent in the patient’s chart
Explain the procedure and its purpose to the patient
o After the procedure:
Check the insertion site for infection
Monitor the pressure tracings and record readings
Putting hemodynamic monitoring to use:
o To understand intracardiac pressures, picture the cardiovascular system as a
continuous loop with constantly changing pressure gradients that keep the blood
moving.
Right Atrial Pressure (RAP) or Central Venous Pressure (CVP)
The RAP reflects right atrial, or right heart function and end-diastolic
pressure
• Normal: 1 to 6 mm Hg / 1.34 to 8 cm H20
• Elevated value suggests: right sided heart failure, fluid volume
overload, tricuspid valve stenosis or insufficiency, constrictive
pericarditis, pulmonary hypertension, cardiac tamponade, or right
ventricular infarction
• Low value suggests: reduced circulating blood volume
Right Ventricular Pressure (RVP)
Right ventricular (RV) systolic pressure normally equals pulmonary
artery pressure; RV end-diastolic pressure, which equals right atrial
pressure, reflects RV function
• Normal: systolic: 15 to 25 mm Hg; diastolic: 0-8 mm Hg
• Elevated value suggests: mitral valve stenosis or insufficiency,
pulmonary disease, hypoxemia, constrictive pericarditis, chronic
heart failure, atrial and ventricular septal defects, and patent ductus
arteriosus
Pulmonary Artery Pressure (PAP)
Pulmonary artery systolic pressure reflects right ventricular function and
pulmonary circulation pressures. Pulmonary artery diastolic pressure
reflects left ventricular pressures, specifically left-ventricular end-
diastolic pressure.
• Normal: Systolic, 15 to 25 mm Hg; Diastolic: 8 to 15 mm Hg; mean:
10 to 20 mm Hg
• Elevated value suggests: Left-sided heart failure, increased
pulmonary blood flow (left or right shunting as in artial or ventricular
septal defects), or any condition causing increased pulmonary
arteriolar resistance.
Pulmonary Artery Wedge Pressure (PAWP)
PAWP reflects left atrial and left ventricular pressures unless the patient
has mitral stenosis. Changes in PAWP reflect changes in left ventricular
filling pressure. The heart momentarily relaxes during diastole as it fills
with blood from the pulmonary veinsl this permits the pulmonary
vasculature, left atrium, and left ventricle to act as a single chamber.
• Normal: mean pressure: 6 to 12 mm Hg
• Elevated value suggests: left-sided heart failure, mitral stenosis or
insufficiency, and pericardial tamponade
• Low value suggests: hypovolemia
Left Atrial Pressure
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This value reflects left ventricular end-diastolic pressure in patients
without mitral valve disease.
• Normal: 6 – 12 mm Hg
Cardiac Output
Cardiac output is the amount of blood ejected by the heart each minute
• Normal: 4 to 8 L; varies with the patient’s weight, height, and body
surface area. Adjusting the cardiac output to the patient’s size yields
a measurement called the cardiac index
Chest X-ray (CXR)
Non-invasive test
Provides radiographic picture of the heart and lungs
Nursing Interventions:
o Determine the patient’s ability to hold his breath
o Ensure that the patient removes jewelry before the test
Blood Tests
Laboratory test of a blood sample
Blood Chemistries:
Sodium Glucose BUN (Blood Urea Nitrogen) Troponin T
Potassium Cholesterol Creatinine Bilirubin
Magnesium Triglicerides CK (creatinine kinase) AST (aspartate amino-
transferase)
Calcium Uric Acid CK isoenzymes Alanine amino-transferase
Phosphorus Bicarbonate Troponin I
Nursing Interventions:
o Note any drugs that may alter test results
o Restrict the patient’s exercise before the blood sample is drawn
o Withold I.M. injections or note the time of the injection on the laboratory slip
(alter CK levels)
o Withhold any food and fluids as ordered
o Assess the venipuncture site for bleeding
Hematologic Studies:
RBCs ESR (Erythrocyte PTT (Partial Hemoglobin
Sedimentation Rate) Thromboplastin Time)
WBCs PT (Prothrombin time) Platelets HCT (Hematocrit)
Nursing Interventions:
o Note any drugs that may alter test results before the procedure
o Assess the venipuncture site for bleeding after the procedure
Arterial Blood Gas (ABG) Analysis
Assessment of tissue oxygenation, ventilation, and acid-base status
Test of arterial blood
Nursing Interventions:
o Before the procedure:
Note whether the patient needs supplemental oxygen or mechanical
ventilation
Perform Allen’s test prior to obtaining sample
Avoid using a limb with an arteriovenous shunt
o After the procedure:
Check the site for bleeding
Maintain a pressure dressing
Check peripheral pulses in the affected limb
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Doppler Ultrasound
Non-invasive test that transforms echoes from soundwaves into audible sounds
Examination of blood flow in peripheral circulation
Nursing Interventions:
o Determine the patient’s ability to lie still
o Explain the procedure
Venogram
Visualization of the veins after I.V. injection of a dye
Diagnosis of deep vein thrombosis or incompetent valves
Nursing Interventions:
o Before the procedure:
Withhold food and fluids after midnight
Record the patient’s baseline vital signs and peripheral pulses
Place obtained written consent in the patient’s chart
Note the patient’s allergy to seafood, iodine, or radiopaque dye
before the test
Inform the patient about possible flushing of the face or throat irritation
form the injection
Ensure the patient is adequately hydrated
o After the procedure:
Check the injection site for bleeding and hematoma
Force fluids unless contraindicated
Evaluate for signs of delayed reaction to radiopaque dye
Assess vital signs and compare to baseline
Pulse Oximetry
Non-invasive procedure using infrared light to measure arterial oxygen saturation in the
blood
Continuous assessment of oxygen saturation assists in pulmonary assessment of patient
and weaning patient from a ventilator.
Nursing Interventions:
o Avoid placing the pulse oximetry sensor on an extremity that has impeded
blood flow.
o Protect sensor from bright light
o Attach the monitoring sensor to a fingertip, earlobe, or toe.
o Consider using the earlobe if the patient has artificial nails, nail tips, or nail polish,
as these may interfere with light transmission.
Some sensors can accurately read through these as long as polish is removed, but
this isn’t recommended.
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o Restrictions in activity related to environmental temperature; for example, hot or
cold weather may interfere with patient’s ability to take walks or go outside
Social Impact
o Changes in dietary habits such as dining out
o Changes in sexual function
o Changes in role performance including work, family roles
o Social isolation