cardiac introduction, history, physical examination, laboratory issues, Nursing care

1. CARDIAC SYSTEM
Presented By:
By Lehulu T.

2. Normal anatomy & physiology
CVS
• Consists: heart, arteries, veins, capillaries
• Functions:
1. circulation of blood
2. delivery of oxygen and other nutrients to
tissues of the body
3. removal of carbon dioxide and other
products of cellular metabolism

3.  HEART
 Anatomy and physiology:
A. Heart wall/ Layers
1. pericardium
a. fibrous
b. serous
2. epicardium
3. myocardium
4. endocardium

4. B. Chambers
1. Atria a. right
b. left
2. Ventricles a. right
b. left
C. Valves
1. Atrioventricular valves
a. Mitral valve/bicuspid
b. Tricuspid valve

5. AV valve Function
- permit unidirectional flow of blood from
specific atrium to specific ventricle during
ventricular diastole
- prevent reflux of blood during ventricular
systole
- valve leaflets open during ventricular diastole
and close during ventricular systole; valve
closure produces the first heart sounds (S1)

6. 2. Semilunar valves
a. Pulmonic valve
b. Aortic valve
Functions:
- permit unidirectional flow of blood from
specific ventricle to arterial vessel during
ventricular systole
-prevent reflux during ventricular diastole
- open when ventricles contract and close during
ventricular diastole; closure produces the
second heart sound (S2)

7. D. Conduction System
1. Sino atrial (SA) node
2. Intermodal Tracts – at upper right atrium
3. Atrioventricular (AV) node
4. Bundle of His – group of muscle fibers
- right bundle branch
- left bundle branch
5. Purkinje fibers – through out ventricles
* Electrical activity of heart can be visualized by
ECG

8. E. Coronary Circulation
1. Arteries
a. right coronary artery
b. left coronary artery
2. Veins
a. coronary sinus veins – group of small
veins

9.  VASCULAR SYSTEM
Functions:
a. supply tissues with blood
b. remove wastes
c. carry deoxygenated
blood back to the heart

10. TYPES OF BLOOD VESSELS
A. Arteries
B. Arterioles
C. Capillaries: the following exchanges
occur:
- oxygen and carbon dioxide
- solutes between the blood and tissues
- fluid volume transfer between the plasma
and interstitial spaces
D. Veins
E. Venules

11. ASSESSMENT
 HISTORY TAKING
A. Presenting problem
1. Nonspecific symptoms
include:-
- fatigue - cough
- Headache - weight loss/gain
- syncope (dizziness) - difficulty of
sleeping
- anorexia

12. 2. Specific signs and symptoms
a. chest pain
b. dyspnea (shortness/difficulty of breath)
c. orthopnea / paroxysmal nocturnal dyspnea
d. palpitations
e. edema
f. cyanosis
B. Lifestyle: occupation, hobbies, financial
status, stressors, exercise, smoking, living
conditions

13. C. Use of medications: OTC drugs,
contraceptives, cardiac drugs
D. Personality: Type A, manic-depressive,
anxieties
E. Nutrition: dietary habits, cholesterol, salt
intake, alcohol consumption
F. Past Medical History
G. Family history: heart disease (congenital,
acute, chronic); risk factors (DM,
hypertension, obesity)

14. PHYSICAL EXAMINATION
A. Skin and mucous membranes:
- color/texture, temperature, hair distribution
on extremities, atrophy or edema, petechial
B. Peripheral pulses:
- palpate and rate all arterial pulses (temporal,
carotid, brachial, radial, femoral, popliteal,
dorsalis pedis and posterior tibia) on scale of:
0=absent
1=weak
2=normal
3=full /bounding

15. C. Measure and record blood pressure
D. Inspect and palpate the neck vessels:
a. jugular veins: note; location,
characteristics, jugular venous pressure
b. carotid arteries: location and
characteristics
E. Auscultate heart sounds
- normal - (S1, S2)
- abnormal - gallop (S3, S4)
- murmur
- pericardial friction rub

16. LABORATORY / DIAGNOSTIC
TESTS
A. Chemistry and electrolyte analysis
1. Cardiac enzymes: in MI
a. Troponin T: detected 3-12 hours after chest
pain
b. Troponin I: detected 3-12 hrs.
c. creatinine phosphokinase (CPK ): 6-12Hrs
d. Aspartate aminotransferase (AST) (SGOT):
with in 24 Hrs. after chest pain
e. Lactic dehydrogenase (LDH): with in 36
Hrs.

17. 2. Electrolytes
a. Sodium (Na): 135-145meq/L
- hyponatremia: may cause fluid excess
- hypernatremia: fluid deficit
b. Potassium (K): 3.5-5 meq/L
- Inc. or Dec. levels can cause dysrhythmias
c. Magnesium (Mg): 1.3-2.1 meq/L
- decrease levels can cause dysrhythmias

18. d. Calcium (Ca): 4.5-5.3 meq/L:
-Normal values for blood clotting and
neuromuscular activity
- decrease levels cause tetany,
- Inc. levels causes muscle atony
- Dec. and Inc. levels causes dysrhythmias
3. Serum Lipids
a. Total Cholesterol : 150-200mg/dl:
- high levels predispose to atherosclerotic
Heart disease

19. b. High density lipids (HDL): 30-85 mg/dl
- low levels predispose to CVD
c. Low density lipids (LDL): 50-140 mg/dl:
- high levels predispose to atherosclerotic
plaque formation
d. Triglycerides :10-150 mg/dl:
- high levels increase risk of atherosclerotic
heart disease

20. B. Hematologic Studies
1. CBC – their number,size,infections
2. Coagulation time: 5-15mins; Inc. levels
indicate bleeding tendency, used to monitor
heparin Rx.
3. Prothrombin time (PT): 9.5-12sec.; used to
monitor warfarin Rx.
4. Activated partial thromboplastin time (APTT):
20-45sec; used to monitor heparin therapy
5. Erythrocyte sedimentation rate(ESR) :
<20mm/hr; Inc. level indicate inflammatory
process

21. C. Urine Studies (U/A)
D. Electrocardiogram (ECG/EKG)
1. Noninvasive ECG – a graphic record of
the electrical activity of the heart
2. Portable recorder (Holter monitor) –
provides continuous recording of ECG for up
to 24 hrs.
3. Exercise ECG (stress test): the ECG is
recorded during prescribed exercise; may
show heart disease when resting ECG does
not.
E. Echocardiogram: noninvasive recording of the
cardiac structures using ultrasound

22. F. Cardiac catheterization: invasive, but often
definitive test for diagnosis of cardiac
disease.
1. A catheter is inserted into the right or left
side of the heart to obtain information
2. Purpose: to measure intracardiac pressures
and oxygen levels in various parts of the
heart; with injection of a dye,
• allows visualization of the heart chambers,
blood vessels and blood flow (angiography)

23. 3. Nursing care for C.catheterization
 prior to the test
- informed consent
- any allergies especially to iodine
- keep client on NPO for 8-12 hrs.
- record V/S, height, weight
- inform client that a feeling of warmth
and fluttering sensation as catheter is
inserted

24.  post test
- assess circulation to the extremity used for
catheter insertion
- check peripheral pulses, color, sensation of
affected extremity
- if protocol requires, keep affected extremity
straight for approximately 8 hrs.
- observe catheter insertion site for swelling,
bleeding
- assess V/S and report for significant changes

25. G. Coronary arteriography
1. visualization of coronary arteries by injection
of radiopaque dye/ contrast medium and
recording on a movie film.
2. Purpose: evaluation of heart disease and
angina, location of areas of infarction and
extent of lesions, ruling out coronary artery
disease in clients with MI.
3. Nursing care: same as cardiac catheterization

26. ANALYSIS
Nursing diagnosis for the client with CVD include
A. Fluid volume excess r/t…as evidenced by..
B. Decreased cardiac output
C. Altered peripheral tissue perfusion
D. Impaired skin integrity
E. Risk for activity intolerance
F. Pain
G. Ineffective coping
H. Fear
I. Anxiety

27. PLANNING
GOALS
A. Fluid imbalance will be resolved, edema will be
minimized
B. Cardiac output will be improved.
C. peripheral tissue perfusion will be improved
D. Adequate skin integrity will be maintained
E. Activity intolerance will progressively resolved
F. Pain in the chest will be diminished
G. Client’s level of fear and anxiety will be decreased

28. INTERVENTIONS
CARDIAC MONITORING
A. ECG
1. P wave: produced by atrial depolarization;
indicates SA node function
2. P-R interval
a. indicates AV conduction time or the time
it takes an impulse to travel from the atria
down and through the AV node
b. measured from beginning of P wave to
beginning of QRS complex

29. 3. QRS complex
a. indicates ventricular depolarization
b. measured from onset of Q wave to end of S wave
4. ST segment
a. indicates time interval between complete
depolarization of ventricles and repolarization of
ventricles
b. measured after QRS complex to beginning of T
wave
5. T wave
a. represents ventricular repolarization
b. follows ST segment

30. HEMODYNAMIC MONITORING
(Swan Ganz Catheter)
A. A multilumen catheter with a balloon tip that
is advanced through the superior vena cava
into the RA, RV, and Pulmonary Artery/PA.
When it is wedged it is in the distal arterial
branch of the pulmonary artery.
B. Purpose:
1. Proximal port: measures RA pressure
2. Distal port:
a. measures PA pressure

31. b. normal values: PA pressure (systolic and
diastolic) less than 20mmHg
C. Nursing care
1. a sterile dry dressing should be applied to
site and changed Q 24 hours; inspect site
daily and report signs of infection
2. if catheter is inserted via an extremity,
immobilize extremity to prevent catheter
dislodgment or trauma.

32. 3. Observe catheter site for leakage
4. Continuously monitor PA systolic and
diastolic pressures and report significant
variations
5. Maintain client in same position for each
reading
6. Record PA systolic and diastolic readings
at least every hour

33. Central venous pressure (cvp)
A. Obtained by inserting a catheter into the
external jugular, ante cubital, or femoral vein
and threading it into the vena cava. The
catheter is attached to an IV infusion and
H2O manometer by a three way stopcock
B. Purposes:
1. Reveals RA pressure, reflecting alterations
in the RV pressure

34. 2. Provides information concerning blood
volume and adequacy of central venous
return
3. Provides an IV route for drawing blood
samples, administering fluids or medication,
and possibly inserting a pacing catheter
C. Normal range is 4-10 cmH20;
- elevation indicates hypervolemia,
- decreased level indicates hypovolemia
D. Nursing care
1. Ensure client is relaxed

35. 2. Maintain zero point of manometer always at
level of right atrium (miaxillary line)
3. Determine patency of catheter by opening IV
infusion line
4. Turn stopcock to allow IV solution to run into
manometer to a level of 10-20cm above
expected pressure reading
5. Turn stopcock to allow IV solution to flow
from manometer into catheter; fluid level in
manometer fluctuates with respiration

36. 6. Stop ventilatory assistance during
measurement of CVP
7. After CVP reading, return stopcock to IV
infusion position
8. Record CVP reading and position of client
EVALUATION
• Act of examining improvements previously
stated problems
• May lead to re assessment

37. • Thanks