Case study of TOF

INTRODUCTION

“You can never be wrong when you think of your patient”
-Rabj

Our heart plays an important role in our body. It has four chambers, muscular organ that
functions as a powerful pump. It continuously pumps blood through the body’s extensive network of
arteries and veins. This circulation of blood delivers oxygen and nutrients to the body while removing
waste products.

Congenital heart disease is a type of defect or malformation in one or more structures of the
heart or blood vessels that occurs before birth. Many heart defects and common health condition such
as heart disease occur as a result of interactions of multiple gene mutations and environmental
influences.

These defects occur while the fetus is developing in the uterus and affect 8-10 out of every
1,000 children. Congenital heart defects may produce symptoms at birth, during childhood, and
sometimes not until adulthood. About 500,000 adults in the U.S. have congenital heart disease
(http://www.webmd.com/heart-disease/guide/congenital-heart-disease?page=2).

According to the Mortality Country Fact Sheet of the year 2006, the top 4 causes of death in
children are congenital anomalies. It covers about 8% out of 100% total percentage of deaths among
children in both national and local areas. (www.who.international.mortality.philippines.com)

Patient X is a 9 year old, female, who was diagnosed with congenital heart defect, cyanotic to
consider tetralogy of fallot. It defined as defects with decrease pulmonary blood flow. It is a form of
congenital heart defect which includes four abnormalities – narrowing of the pulmonary artery, a septal
defect between the ventricles, hypertrophy of the right ventricles and displacement of the aorta to the
right. The condition results in deficient oxygenation of the blood with cyanosis, dyspnea, polycythemia,
clubbing of the fingers.

We choose this as the prime proponent of this case presentation primarily because the content
of this presentation tackles about the condition of the patient whose the course of the disease, its
management of both medical and nursing interventions and as well as pertinent health teachings which
the group find the case as medium for continuing professional learning. Nevertheless it serves as a tool
not only for the betterment of the patient and her family but also for us nurses to be able to learn more
about the realms of medical-surgical nursing its importance and implications.

As a member of the health team- we should be the one that drives the family and with the
patient itself to empower them to become more self reliant with their own health.

OBJECTIVES

Discuss congenital heart defect;
present the medical interventions done to the patient;
identify needs of the patient and formulate a nursing care plan for each;
itemize the various drugs under the patient’s treatment regimen with information relevant to
the patient’s condition;
determine the prognosis of the patient with the following criteria: duration of illness, onset,
precipitating factors, willingness to take medications, age, environment, and family support;
and, state the general prognosis of the patient and;
formulate health teachings to the mother of our client regarding the continuity of treatment.

PATIENT’S PROFILE

Name: Heart

Age: 9 years old

Address: Florida, Kapalong, Davao del Norte

Civil Status: Single

Father’s Name: Superior Vena Cava

Mother’s Name: Inferior Vena Cava

Occupation: Father: Farmer

Mother: Housewife

Date of Birth: February 23, 2001

Admission Date/Time: May 28, 2010/ 3:45 pm

Attending Physician: Dr. Gemma Maranian

Diagnosis: Congenital heart defect, cyanotic type t/c TOF

PHYSICAL ASSESSMENT

General Survey

Upon seeing the patient, she has an ectomorphic body built. She has an IVF of D5LR 1 liter at
108 cc/hr infusing well at right metalcarpal vein at 650 level and hooked to oxygen inhalation at 2 lpm
via nasal cannula and was placed on a high back rest, she has difficulty in breathing and has a capillary
refill time of 3 seconds. She has a foley catheter attached to uro bag draining to 100cc level with amber
yellow color urine. The patient is on diet as tolerated with strict aspiration precaution.

Vital Signs

Temp – 38.9°C

PR- 120 bpm

RR- 38 cpm

CR- 120 bpm

BP – 90/60 mmHg

Skin

She has a darker skin complexion and is evenly distributed. Skin is dry and warm to touch.
Clubbing of finger nails noted with bluish discoloration of nailbeds on both upper and lower
extremitiesm with untimmed and dirty finger nails. She has some round scars on both legs.

Head

Hair is black, long and evenly distributed, no infestations noted upon inspection. Head is
normocephalic with no abnormalities noted.

Eyes

Eyes are symmetrical and are aligned at the upper pinnea of the ear. Iris is color brown and
pupils are equally rounded and are reactive to light accommodation with a diameter of 2 mm. No
lesions or discharges noted upon assessment.

Ears

Ears are symmetrical and are aligned at the outer canthus of the eye. Eardrums are intact with
cerumen noted upon inspection. No lesions, discharges or abnormalities noted.

Nose

Nasal flaring noted. No lesions or discharges noted upon inspection.

Neck and Throat

Patient was able to swallow without any difficulty. Use of accessory muscle was noted. Neck was
able to flex from front to back and side to side without any discomfort. Upon palpation of the neck, no
mass was noted.

Mouth

Lips have bluish discoloration with dry mucous membranes and dry tongue. No lesions or
abnormalities noted.

Chest

Chest is slightly barrel chest with right side of the chest enlarged, with AP diameter of 2:1. Apex
of the heart is at the 4-5th midclavicular line. With clear breath sounds noted with use of accessory
muscles noted.

Abdomen

The abdomen is flat and brown in skin color. Bowel sounds were heard upon auscultation with 5
bowel sounds per minute. No lesions noted upon inspection.

Genito-Urinary

Patient was on folely catheter attached to urobag at 100 cc level with amber yellow colored
urine. No lesions or abnormalities noted.

MEDICAL HEALTH HISTORY

PAST MEDICAL HISTORY

Perinatal
Prenatal check – up was started at the 5th month of pregnancy. Tetanus toxoid 1 was given. The
mother was febrile during the 3rd month of pregnancy. The mother did not consult a physician and there
were no medications taken. Her mother gave birth at home full term via normal spontaneous vaginal
delivery assisted by a hilot on the moonlit night of February 23, 2001. The baby presented poor and
delayed crying with cyanosis.

Past Medical Illness
Her mother noted that at 1 year of age, the patient had an episode of syncope, (-) colds and (+)
cough for one month which led to her admission to a local hospital and then was referred to Davao
Regional Hospital where she was diagnosed with Congenital Heart Disease. 2D Echo was done where it
was found out that the patient had a hole in the heart. Surgical management was advised but not
heeded due to lack of financial resources. She was then discharged with a home medication of
spironolactone (Aldactone) but the patient did not comply. Due to poor compliance to the medication
and advised surgical management, her condition did not alleviate and she experienced on and off
dyspnea, orthopnea and occasional congestion.

Growth and Development
During infancy, she was exclusively breastfed for six months and afterwards she was introduced
to solid foods like cereals and other table foods. Their source of water is from a water pump. The patient
has a good appetite.

Developmental Milestone
The patient was able to attend school from nursery up to kindergarten. Unfortunately, she was
not able to continue her schooling because she finds it difficult to travel by walking.

PRESENT ILLNESS

Heart was doing well on the onset of her present illness. Unexpectedly, after defecating and
performing the Valsalva maneuver, she felt restless, irritable and short of breath. She even uttered
irritably the words, “Unsa man ning sakita ni uy!”. Despite of Heart’s complaint, she wasn’t rushed to
the hospital because of financial constraints. After two days of continually feeling short of breath and
restless, her mother decided to bring her to the Center of Child Health and Development (CCHD) here at
Davao Regional Hospital. Dr. dela Cruz was her attending physician then and she advised Heart’s parents
to admit their child at the Pediatric unit to be able to give the needed interventions for Heart. Thus,
after two days of restlessness, irritability and shortness of breath she was admitted as an in patient at
the Pediatric Unit of Davao Regional Hospital.

FAMILY HEALTH HISTORY
Based on the diagram presented it reveals that on the Paternal side, Rodolfo the grandfather
has a heart problem, while her wife Dolores the Grandmother has no other hereditary disease. Together
they have five children namely: Beth, the eldest who has hypertension, Fe the second child who was
diagnosed with Diabetes Milletus, Bobby the third child and is the father of our patient do not have any
hereditary diseases, Bernie the fourth child has Heart Problem and is said to have inherited it to their
father and Flor as the youngest do not have any other hereditary diseases aside from mentioned above.
On the Maternal side the grandfather of our patient Domingo was diagnosed with hypertension
while her wife Primitiva had no other hereditary diseases. They have 3 children namely: Cipriano as the
eldest and has Hypertension, the second child Miraluna and is the mother of our patient, and the
youngest is Felipe and was diagnosed with bronchial asthma.
Generally, other conditions experienced both by the maternal and paternal side are common
colds and cough.

GENOGRAM

PATERNAL SIDE MATERNAL SIDE

Dolores
Rodolfo Primitiva
Domingo

Bobby Flor
Beth FE Bernie
32 ╬ Cipriano Miraluna Felipe ╬

= Hypertension
Heart Kristine
= Diabetes Mellitus

╬ = Bronchial Asthma

= Heart Problem

COURSE IN THE WARD

I. Ongoing Diagnostic Work-ups

1.1 Complete Blood Count

Definition:
The CBC is used as a broad screening test to check for such disorders as anemia,
infection, and many other diseases. It is actually a panel of tests that examines different
parts of the blood and includes the following:

 White blood cell (WBC) count is a count of the actual number of white blood cells per
volume of blood. Both increases and decreases can be significant.

 White blood cell types (WBC differential). There are five different types of white blood
cells, each with its own function in protecting us from infection. The differential
classifies a person's white blood cells into each type: neutrophils (also known as segs,
PMNs, granulocytes, grans), lymphocytes, monocytes, eosinophils, and basophils.

 Red blood cell (RBC) count is a count of the actual number of red blood cells per volume
of blood. Both increases and decreases can point to abnormal conditions.

 Hemoglobin (Hgb). The hemoglobin molecule fills up the red blood cells. It carries
oxygen and gives the blood cell its red color. The hemoglobin test measures the amount
of hemoglobin in blood and is a good measure of the blood's ability to carry oxygen
throughout the body.

 Hematocrit (HCT, packed cell volume, PCV). This test measures the amount of space
(volume) red blood cells take up in the blood. The value is given as a percentage of red
blood cells in a volume of blood. For example, a hematocrit of 38 means that 38% of the
blood's volume is made of red blood cells. Hematocrit and hemoglobin values are the
two major tests that show if anemia or polycythemia is present.

 Platelet (thrombocyte) count is the number of platelets in a given volume of blood. Both
increases and decreases can point to abnormal conditions of excess bleeding or clotting.
Mean platelet volume (MPV) is a machine-calculated measurement of the average size
of your platelets. New platelets are larger, and an increased MPV occurs when increased
numbers of platelets are being produced. MPV gives your doctor information about
platelet production in your bone marrow.

 Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs.
The MCV is elevated when your RBCs are larger than normal (macrocytic), for example
in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are
smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemias.

 Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of oxygen-
carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a
higher MCH, while microcytic red cells would have a lower value.

 Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average
concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia)
are seen in conditions where the hemoglobin is abnormally diluted inside the red cells,
such as in iron deficiency anemia and in thalassemia. Increased MCHC values
(hyperchromia) are seen in conditions where the hemoglobin is abnormally
concentrated inside the red cells, such as in burn patients and hereditary spherocytosis,
a relatively rare congenital disorder.

 Red cell distribution width (RDW) is a calculation of the variation in the size of your
RBCs. In some anemias, such as pernicious anemia, the amount of variation
(anisocytosis) in RBC size (along with variation in shape – poikilocytosis) causes an
increase in the RDW.

Nursing Care Prior to Procedure:
1. Explain test procedure. Explain that slight discomfort may be felt when skin is
punctured.
2. Avoid stress if possible because altered physiologic status influences and
changes normal values.

3. Dehydration or over hydration can dramatically alter values; for example, large
volumes of IV fluids can dilute the blood and values will appear as lower counts.
The presence of either these states should be communicated to the laboratory.
4. Fasting is not necessary. However, fat-laden meals may alter some test results
as a result of lipidemia.

Nursing Care During and After the Procedure:
1. Apply manual pressure and dressings to the puncture site on removal of the
needle.
2. Monitor of the puncture site for oozing or hematoma formation. Maintain
pressure dressings if necessary. Notify physician for unusual problems with
bleeding.
3. Resume normal activities and diet.

Result with indications:
Hematology/CBC
Date Test Result Normal Values Indication

May 28, 2010 Hemoglobin (Hgb): 225 120 –140 mg/dl May be increased when
mg/dl the body perceives low
blood oxygenation that
can be due to decreased
cardiac output

Leukocyte number 4.6 4.5 – 11.0 x 109 /L May be increased with
concentration: or 4,500 - infections, inflammation,
11,000/mcL3 cancer, leukemia;
decreased with some
medications (such as
methotrexate), some
autoimmune conditions,
some severe infections,
bone marrow failure, and
congenital marrow
aplasia (marrow doesn't
develop normally).

Segmenters: 0.56 2.5-7.5 x 109/L High count may indicate
bacterial infection, burns,
stress, and inflammation.
Low count may indicate
radiation exposure, drug
toxicity, vitamin B12

deficiency, and
systematic lupus
erythematosus (SLE).

Eosinophils: 0.02 High Eosinophil count
may indicate an allergic
reactions, parasitic
infections, autoimmune
diseases. While a low
count may indicate drug
toxicity or stress.

Thrombocyte: 84 150.0– 400.0 x Decreased or increased
109 /L with conditions that
or affect platelet
150,000 - production; decreased
400,000/mcL3 when greater numbers
used, as with bleeding;
decreased with some
inherited disorders (such
as Wiskott-Aldrich,
Bernard-Soulier), with
Systemic lupus
erythematosus,
pernicious anemia,
hypersplenism (spleen
takes too many out of
circulation), leukemia,
and chemotherapy

Erythrocyte: 0.77 Decreased with anemia;
increased when too many
made and with fluid loss
due to diarrhea,
dehydration, and burns.

Hematocrit 0.77 Male: 0.40 – 0.50 Increased with
Female: 0.37- dehydration, fluid loss
0.43
May 30, 2010 Erythrocyte Volume 0.83 Male: 0.40 – 0.50 Increased with
Fraction: Female: 0.37- dehydration, fluid loss
0.43

June 4, 2010 Hematocrit 0.52 Male: 0.40 – 0.50 Increased with
Female: 0.37- dehydration, fluid loss
0.43

Benefits:
A complete blood count may be done to:
 Find the cause of symptoms such as fatigue, weakness, fever, bruising, or weight
loss.
 Find anemia.
 See how much blood has been lost if there is bleeding.
 Diagnose polycythemia and leukemia.
 Find an infection.
 Check how the body is dealing with some types of drug or radiation treatment.
 Check how abnormal bleeding is affecting the blood cells and counts.
 Screen for high and low values before a surgery.
 See if there are too many of too few of certain types of cells. This may help find
other conditions, such as too many eosinophils may mean an allergy or asthma
is present.
 As a part of regular physical examination. A blood count can give valuable
information about the general state of your health.

Risk:
There is a little chance of a problem from having a blood sample taken from a vein.
 You may get a small bruise at the site. You can lower the chace of bruising by
keeping pressure on the site for several minutes.
 In rare cases, the vein may become swollen after the blood sample is taken. This
problem is called phlebitis. A warm compress can be used several times a day to
treat this.
 Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin,
warfarin (Coumadin), and other blood-thinning medicines can make bleeding
more likely. If you have bleeding or clotting problems, or if you take blood-
thinning medicine, tell your doctor before your blood sample is taken.

1.2 Chest Radiography
APL (Apicolordotic) View

Definition:
An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat
medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose
of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and
most frequently used form of medical imaging.

1. Explain test purpose, procedure and interfering factors. Emphasize that chest x-ray
is painless.
2. Have your client to remove some or all of clothes and wear a gown during the exam.
3. Have your client remove jewelry, dentures, eye glasses and any metal objects or
clothing that might interfere with the x-ray images.
4. Follow guidelines for safe, effective, informed pretest care.

Nursing care during and after the procedure:
1. Due to the cool temperature in the examination room and the coldness of the
recording plate, some client may experience slight discomfort. Individuals with
arthritis or injuries to the chest wall, shoulders or arms may have discomfort trying
to stay still. Assist them in finding the most comfortable position possible that still
ensures diagnostic image quality.
2. After the procedure, return client’s jewelry, dentures, eye glasses and other
belongings.

3. Follow safe, effective, informed post test care.

Results with indication:
Date: May 28, 2010

Chest APL: Peripheral pulmonary vessels are accentuated. Heart is slightly enlarged.
Diaphragm and bony thorax are unremarkable. Soft tissue does not appear unusual.

Impression: Mild Cardiomegaly with Pulmonary Congestion. Congenital Heart
Disease is entertained.

Benefits
 No radiation remains in a patient's body after an x-ray examination.
 X-rays usually have no side effects in the diagnostic range.
 X-ray equipment is relatively inexpensive and widely available in emergency rooms,
physician offices, ambulatory care centers, nursing homes and other locations,
making it convenient for both patients and physicians.
 Because x-ray imaging is fast and easy, it is particularly useful in emergency
diagnosis and treatment.

Risk
 There is always a slight chance of cancer from excessive exposure to radiation.
However, the benefit of an accurate diagnosis far outweighs the risk.
 The chest x-ray is one of the lowest radiation exposure medical examinations
performed today. The effective radiation dose from this procedure is about 0.1 mSv,
which is about the same as the average person receives from background radiation
in 10 days.
 Women should always inform their physician or x-ray technologist if there is any
possibility that they are pregnant.

1.3 Arterial Blood Gas

Definition:
Arterial Blood Gases is a means of assessing the adequacy of oxygenation and ventilation, to
evaluate acid base status by measuring the respiratory and non respiratory components and
to monitor effectiveness of therapy. They are also used to monitor critically ill patients, to
establish baseline values in the perioperative and postoperative period, to detect and treat
electrolyte imbalances, to titrate appropriate oxygen flow rates, etc.

An ABG measures:
 Partial pressure of oxygen (PaO2). This measure the pressure of oxygen dissolved in
the blood and how well oxygen is able to move from the airspace of the lungs into
the blood.
 Partial pressure of carbon dioxide (PaCO2). This measures how much carbon
dioxide is dissolved in the blood and how well carbon dioxide is able to move out of
the body.
 pH. The pH measures hydrogen ions (H+) in blood. The pH of blood is usually
between 7.35 and 7.45. A pH of less than 7.0 is called acid and a pH greater than 7.0
is called basic (alkaline). So blood is slightly basic.
 Bicarbonate (HCO3). Bicarbonate is a chemical (buffer) that keeps the pH of blood
from becoming too acidic or too basic.
 Oxygen content (O2CT) and oxygen saturation (O2Sat) values. O2 content
measures the amount of oxygen in the blood. Oxygen saturation measures how
much of the hemoglobin in the red blood cells is carrying oxygen (O2).

1. Explain the purpose and procedure for obtaining arterial blood sample.
2. If the patient is apprehensive, explain that a local anesthetic can be used.
3. Follow safe, effective, informed care.

1. Evaluate color, motion, sensation, degree of warmth, capillary refill time, and
quality of pulse in the affected extremity or at the puncture site.
2. Monitor puncture site and dressing for arterial bleeding for several hours. No
vigorous activity of the extremity should be undertaken for 24 hours.
3. Follow safe, effective, informed post test care.

Result with indications:
Date/Time Test Test Normal Values Indication
Result
May 30, pH: 7.231 7.35 – 7.45 The pH or H+ indicates if a patient is
2010/ 11:33 acidotic (pH < 7.35; H+ >45) or
alkalemic (pH > 7.45; H+ < 35). In
this situation, the patient is
acidotic.

Partial pressure 30.5 35-45 mm Hg The carbon dioxide partial pressure
of carbon dioxide (4.6 – 5.9 k Pa) (PaCO2) indicates a respiratory
(PaCO2): problem: for a constant metabolic
rate, the PaCO2 is determined
entirely by ventilation. A high
PaCO2 (respiratory acidosis)
indicates underventilation, a low
PaCO2 (respiratory alkalosis) hyper-
or overventilation. PaCO2 levels can
also become abnormal when the
respiratory system is working to
compensate for a metabolic issue
so as to normalize the blood pH. An
elevated PaCO2 level is desired in
some disorders associated with
respiratory failure; this is known as
permissive hypercapnia.

Partial pressure 30.5 75-100 mm Hg (9.9 A low O2 indicates that the patient
of oxygen – 13.2 k Pa) is not respiring properly, and is

(PaO2): hypoxemic. At a PaO2 of less than
60 mm Hg, supplemental oxygen
should be administered. At a PaO2
of less than 26 mm Hg, the patient
is at risk of death and must be
oxygenated immediately.

Bicarbonate 13.3 20-29 mEq/L The HCO3− ion indicates whether a
(HCO3): (20 – 29 mmol/L) metabolic problem is present (such
as ketoacidosis). A low HCO3−
indicates metabolic acidosis, a high
HCO3− indicates metabolic alkalosis.
HCO3− levels can also become
abnormal when the kidneys are
working to compensate for a
respiratory issue so as to normalize
the blood pH.

Oxygen 48.7 95%-100% This is the sum of oxygen dissolved
saturation (0.95- 1.00) in plasma and chemically bound to
(O2Sat): hemoglobin. Low percentage of O2
sat indicates low levels of
hemoglobin in the red blood cell,
carrying oxygen.

Base Excess -13.6 -3 to +3 mmol/l The base excess is used for the
(B.E.): assessment of the metabolic
component of acid-base disorders,
and indicates whether the patient
has metabolic acidosis or metabolic
alkalosis. A negative base excess
indicates that the patient has
metabolic acidosis (primary or
secondary to respiratory alkalosis).
A positive base excess indicates
that the patient has metabolic
alkalosis (primary or secondary to
respiratory acidosis).

Benefits
An arterial blood gas (ABG) test is done to:

 Check for severe breathing problems and lung diseases, such as asthma, cystic
fibrosis, or chronic obstructive pulmonary disease (COPD).
 See how well treatment for lung diseases is working.
 Find out if you need extra oxygen or help with breathing (mechanical ventilation).
 Find out if you are receiving the right amount of oxygen when you are using oxygen
in the hospital.
 Measure the acid-base level in the blood of people who have heart failure, kidney
failure, uncontrolled diabetes, sleep disorders, severe infections, or after a drug
overdose.

Risk
There is little chance of a problem from having blood sample taken from an artery.
 You may get a small bruise at the site. You can lower the chance of bruising by
keeping pressure on the site for at least 10 minutes after the needle is removed
(longer if you have bleeding problems or take blood thinners).
 You may feel lightheaded, faint, dizzy, or nauseated while the blood is being drawn
from your artery.
 Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin,
warfarin (Coumadin), and other blood-thinning medicines can make bleeding more
likely. If you have bleeding or clotting problems, or if you take blood-thinning
medicine, tell your doctor before your blood sample is taken.
 On rare occasions, the needle may damage a nerve or the artery, causing the artery
to become blocked.
 Though problems are rare, be careful with the arm or leg that had the blood draw.
Do not lift or carry objects for about 24 hours after you have had blood drawn from
an artery.

1.4 ECG

Definition:
Electrocardiogram (ECG or EKG) is a transthoracic interpretation of the electrical activity of
the heart over time captured and externally recorded by skin electrodes. Electrical impulses
in the heart originate in the sinoatrial node and travel through the intrinsic conducting
system to the heart muscle. The impulses stimulate the myocardial muscle fibres to contract
and thus induce systole. The electrical waves can be measured at selectively placed
electrodes (electrical contacts) on the skin. Electrodes on different sides of the heart
measure the activity of different parts of the heart muscle. It is the best way to measure and
diagnose abnormal rhythms of the heart, particularly abnormal rhythms caused by damage
to the conductive tissue that carries electrical signals, or abnormal rhythms caused by levels
of dissolved alts (electrolytes), such as potassium, that are too high or low. In myocardial
infarction (MI), the ECG can identify damaged heart muscle. But it can only identify damage
to muscle in certain areas, so it can’t rule out damage in other areas. The ECG cannot
reliably measure the pumping ability of the heart; for with ultrasound-based
(echocardiography) or nuclear medicine test are used.

Procedure:
1. Have the patient assume a supine position; however, recordings can be taken during
exercise.
2. Prepare the skin sites and, if necessary, shave and place electrodes on the four
extremities and on specific chest sites. Ensure that the right leg is the ground.
3. Remember that all 12 leads can be recorded simultaneously by newer ECG
machines.
4. Remember that a rhythm strip is a 2-minute recording from a single lead, usually
lead II. It is frequently used to evaluate dysrhythmias.
5. Follow safe, effective and informed intra-test care.


1. Explain test purpose, procedure and interfering factors. Emphasize that ECG is
painless and does not deliver electrical current to the body. A resting ECG is no
more than 1-minute record of the heart’s electrical activity.
2. Have the patient completely relax to ensure a satisfactory tracing.
3. Be aware that ideally, the person should rest for 15 minutes before ECG, and longer
if possible.
4. Follow guidelines for safe, effective, informed pretest care.

1. Recognize the limitations of an ECG. A normal ECG does not rule out coronary artery
disease or areas of cardiac ischemia. Conversely, an abnormal ECG in and of itself
does not always signify heart disease.
2. Interpret test results and counsel and monitor the patient appropriately. A resting
ECG is usually normal in those patients who experience only angina. It can provide
evidence of prior heart damage. The ECG is one diagnostic tool within a repertoire
of diagnostic modalities and should be viewed as such. The presence or absence of
heart disease should not be presumed solely on basis of ECG.
3. Follow guidelines for safe, effective, informed post-test care.

1.5 Two Dimensional Echocardiography (2 D Echo)

Definition:
An echocardiogram (also called echo, transthoracic echocardiogram or TTE, exercise or
stress echocardiogram, dobutamine stress echocardiogram or DSE, or transesophageal
echocardiogram or TEE) is a noninvasive (the skin is not pierced) procedure used to assess
the heart's function and structures. A transducer (like a microphone) sends out ultrasonic
sound waves at a frequency too high to be heard. When the transducer is placed on your
chest at certain locations and angles, the ultrasonic sound waves move through the skin and
other body tissues to the heart tissues, where the waves echo off of the heart structures.
The transducer picks up the reflected waves and sends them to a computer. The computer
interprets the echoes into images of the heart walls and valves.

An echocardiogram can utilize one or more of four special types of echocardiography:
 M-Mode echocardiography: This is the simplest type of echocardiography. It
produces an image that is similar to a line tracing rather than an actual picture of
heart structures. M-mode echo is useful for measuring heart structures, such as the
heart's pumping chambers, the size of the heart itself, and the thickness of the heart
walls.
 Doppler echocardiography: This Doppler technique is used to measure and assess
the flow of blood through the heart's chambers and valves. The amount of blood
pumped out with each beat is an indication of the heart's functioning. Also, Doppler
can detect abnormal blood flow within the heart, which can indicate a problem with
one or more of the heart's four valves or with the heart's walls.
 Color Doppler: Color Doppler is an enhanced form of Doppler echocardiography.
With color Doppler, different colors are used to designate the direction of blood
flow. This simplifies the interpretation of the Doppler technique.
 2-D (2-dimensional) echocardiography: This technique is used to "see" the actual
structures and motion of the heart structures. A 2-D echo view appears cone-
shaped on the monitor, and the real-time motion of the heart's structures can be
observed. This enables the physician to see the various heart structures at work and
evaluate them.
 3-D (3-dimensional) echocardiography: 3-D echo is a relatively new type of echo
that captures 3-dimensional views of the heart structures with greater depth than
the 2-D echo. The live or ("real time") images allow for a more accurate assessment
of heart function by using measurements taken while the heart is beating. 3-D echo
shows enhanced views of the heart's anatomy and can be used to determine the
appropriate plan of treatment for a person with heart disease.

Purpose:
Echocardiography is used to diagnose cardiovascular diseases. In fact, it is one of the most
widely used diagnostic tests for heart disease. It can provide a wealth of helpful information,
including the size and shape of the heart, its pumping capacity and the location and extent
of any damage to its tissues. It is especially useful for assessing diseases of the heart valves.
It not only allows doctors to evaluate the heart valves, but it can detect abnormalities in the
pattern of blood flow, such as the backward flow of blood through partly closed heart
valves, known as regurgitation. By assessing the motion of the heart wall, echocardiography
can help detect the presence and assess the severity of coronary artery disease, as well as
help determine whether any chest pain is related to heart disease. Echocardiography can
also help detect hypertrophic cardiomyopathy. The biggest advantage to echocardiography
is that it is noninvasive (doesn't involve breaking the skin or entering body cavities) and has
no known risks or side effects.

1. Explain test purpose, procedure and interfering factors. Emphasize that 2 D echo
imaging is painless and does not deliver electrical current or whatsoever to the
body.
2. Have the patient completely relax to ensure a satisfactory imaging.
3. Follow guidelines for safe, effective, informed pre-test care.

1. For the procedure, the client may have to remove clothing from waist up. Ensure
privacy by using drapes across the chest and limiting access into the procedure
room during the test.
2. The echocardiography technician will apply warm gel to the client’s chest. Aware
the client beforehand.
3. The client can resume normal activities, unless the physician instructs differently.

II. Medical Management

2.1 Phlebotomy
Definition:
Phlebotomy (A.K.A. venesection and venotomy) is the removal of a certain amount of
blood under controlled conditions. Patients with elevated hematocrits (eg, those with
polycythemia vera) or excessive iron absorption (eg, hemochromatosis) can usually be
managed by periodically (once or twice weekly) removing 1 unit (about 500 ml) of whole
blood. Eventually this depletes patient’s iron stores, thereby rendering the patient iron
deficient and consequently unable to manufacture RBC’s excessively. The actual
procedure for the therapeutic phlebotomy is similar to that for blood donation.

1. Explain test procedure. Explain that slight discomfort may be felt when skin is
punctured.

Phlebotomy consists of venipuncture and blood withdrawal. Standard precautions are
used.
1. Patients are placed in a semi recumbent position. The skin over the antecubital
fossa is carefully cleansed with an antiseptic preparation, a tourniquet is applied
and venipuncture is performed. Withdrawal of 450 ml of blood usually takes less
than 15 minutes.
2. After the needle is removed, patient is asked to hold the involved arm straight
up, and firm pressure is applied with strerile gauze for 2 or 3 minutes or until
bleeding stops. A firm bandage is then applied.

3. Patient should remain recumbent until they feel able to sit up. Patients who
experience weakness or faintness should rest a longer period.
4. Instruct patient to leave the dressing on and to avoid heavy lifting for several
hours, to avoid smoking for 1 hour, to avoid drinking alcoholic beverages for 3
hours, to avoid iron supplements (for those with Polycythemia vera), to increase
fluid intake for 2 days, and to eat healthy meals for 2 weeks.

Benefits
 Decrease over production of RBCs.
 Medical management for patients with polycythemia vera and
hemochromatosis.

Risk
 Fatigue
 Dizzines
 Phlebitis, or puncture site/vein becomes swollen (on rare cases).

2.2 Oxygen therapy

Definition:
Oxygen therapy is the administration of oxygen at a concentration greater than that
found in the environmental atmosphere. At sea level, the concentration of oxygen in
room air is 21%. The goal of oxygen therapy is to provide adequate transport of oxygen
in the blood while decreasing the work of breathing and reducing stress on the
myocardium.
Oxygen transport to the tissue depends on actors such as cardiac output, arterial oxygen
content concentration of hemoglobin, and metabolic requirements. These factors must
be kept in mind when oxygen therapy is considered.

Nursing care prior to procedure:
1. The nurse instructs the patient or family in the methods for administering
oxygen and informs the patient and family that the oxygen is available in gas,
liquid, and concentrated form.

Nursing care during and after procedure:
1. Humidity must be provided while oxygen is used to counteract the dry, irritating
effects of the compressed oxygen on the airway.

III. Medical Management

3.3 Drugs taken by the patient

NAME OF DRUG ORDERED INDICATION MODE OF ACTION PRECAUTION ADVERSE REACTION NURSING
DOSE CONSIDERATION
CEFUROXIME SODIUM 520mg q8 ivtt Pharyngitis, tonsillitis, Second generation Contraindicated in CV: phlebitis, Before
infections of the urinary cephalosporin that patients thrombophlebitis administration,
and lower respiratory inhibits cell-wall hypersensitive to GI: ask patient if he
tracts, and skin and synthesis, promoting drug or other pseuomembranous is allergic to
skin-structure caused osmotic instability; cephalosporins. colitis, nausea, penicillins or
by Streptococcus usually bactericidal. Use cautiously in anorexia, vomiting, cephalosporins.
pneumoniae and S. patients diarrhea Obtain
pyogenes, Haemophilus hypersensitive to Hematologic: specimen for
influenzae, penicillin because transient culture and
Staphylococcus aureus, of possibility of neutropenia, sensitivity tests
E.coli, Moraxella cross-sensitivity eosinophilia, before giving
catarrhalis, Neisseria with other beta- hemolytic anemia, first dose.
gonorrhieae, and lactam antibiotics. thrombocytopenia Therapy may
Klebsiella and Use cautiously in Skin: maculopapular begin while
Enterobacter species. breast-feeding and erythematous awaiting
Serious lower women and in rashes, urticaria, results.
respiratory tract patients with pain, induration, For IM
infections, UTI’s, skin history of colitis sterile abscesses, injection, inject
infections, bone and or renal temperature deep into a
joint infections, insufficiency. elevation, tissue large muscle,
septicemia, meningitis, sloughing at IM such as the
and gonorrhea. injection site gluteus
Uncomplicated UTI. Other: maximus or the
Early Lyme Dieseas hypersensitivity lateral aspect o
(erythema migrans) reactions, serum the thigh
caused by Borrelia sickness, anaphylaxis Cefuroxime
burgdorferi. tablets may be

Secondary bacterial crushed, if
infection of acute absolutely
bronchitis. necessary, for
patients who
can’t swallow
tablets.
If large doses
are given,
therapy is
prolonged, or
patient is at
high risk,
monitor patient
for signs and
symptoms of
superinfection.
Instruct patient
to notify
prescriber
about rash or
evidence of
superinfection.
Advise patient
receiving drug
IV to report
discomfort at IV
insertion site.
Tell patient to
notify
prescriber
about loose
stools or
diarrhea.

CEFTRIAXONE 1.5gm q4 ivtt Uncomplicated Third generation Contraindicated CNS: fever, Before
SODIUM gonococcal cephalosporin that in patients headache, dizziness administration,
vulvovaginitis inhibits cell-wall hypersensitivity to CV: phlebitis ask patient if he is
UTIs; lower synthesis, promoting drug or other GI: allergic to
respiratory tract, osmotic instability; cephalosporins. pseudomembranous penicillins or
gynecologic, bone and usually bactericidal. Use cautiously in colitis, diarrhea cephalosporins.
joint, intra abdominal, patients GU: genital pruritus, Obtain
skin, and skin structure hypersensitive to candidiasis specimen for
infections; septicemia. penicillin because Hematologic: culture and
Meningitis of possibility of eosinophilia, sensitivity tests
Neurological cross-sensitivity thrombocytosis, before giving first
complications, carditis, with other beta- leucopenia dose. Therapy
and arthtritis from lactam antibiotics. Skin: pain, may begin while
penicillin. Use cautiously in induration, awaiting results.
breast-feeding tenderness at For IM
women and in injection site, rash, injection, inject
patients with pruritus deep into a large
history of colitis or Other: muscle, such as
renal insufficiency. hypersensitivity the gluteus
reactions, serum maximus or the
sickness, lateral aspect o
anaphylaxis, chills the thigh.
Monitor PT
and INR in
patients with
impaired vitamin
K synthesis or low
vitamin K stores.
Tell patient to
report adverse
reactions
promptly.

Instruct patient
to report
discomfort at
injection site.
Tell patient to
notify prescriber
about loose stools
or diarrhoea.

PROPRANOLOL 10mg ½ tab po Angina pectoris A non-selective beta Contraindicated CNS: fatigue, Always check
HYDROCHLORIDE To decrease risk of blocker that reduces in patients with lethargy, fever, vivid patient’s apical
death after MI cardiac oxygen bronchial asthma, dreams, pulse before
Supraventricular, demand by blocking sinus bradycardia hallucinations, giving drug. If
ventricular, and atrial catecholamine- and heart block mental depression, extremes in pulse
arrhythmias; induced increases in greater than first light-headedness, rates occur,
tachyarryhtmias caused heart rate, blood degree, dizziness, insomnia withhold drug and
by excessive pressure, and force cardiogenic shock, CV: bradycardia, notify prescriber
catecholamine action of myocardial and overt and hypotension, heart immediately.
during anesthesia, contraction. decompensated failure, intermittent Give drug
huperthyroidism, or Depresses rennin heart failure. claudication, consistently with
pheochromocytopenia. secretion and Use cautiously in intensification of AV meals. Food may
Hypertension prevents patients with block. increase
To prevent frequent, vasodilation of hepatic or renal GI: abdominal absorption of
severe, uncontrollable, cerebral arteries. impairment, non- cramping, propranolol.
or disabling migraine, or allergic constipation, Drug masks
vascular headache. bronchospastic diarrhea, nausea, common signs
Essential tremor diseases, or vomiting and symptoms of
Hypertrophic hepatic diseases Hematologic: shock and
subaortic stenosis and in those taking agranulocytosis hypoglycemia.
other Respiratory: Caution patient
antihypertensives bronchospasm to continue taking
Because drug Skin: rash this drug as
blocks some prescribed, even
symptoms of when he’s feeling

hypoglycemia, use well.
cautiously in Instruct patient
patients who have to take drug with
diabetes mellitus. food.
Use cautiously in Tell patient not
patients with to stop drug
throtoxicosis suddenly because
becaude drug may this can worsen
mask some signs chest pain and
and symptoms of trigger a heart
the disorder. attack.
Elderly patients
may experience
enhanced adverse
reactions and may
need dosage
adjustment.
DIAZEPAM 1ml ivtt Anxiety Unknown. A Contraindicated CNS: drowsiness, Use Diastat
Acute alcohol benzodiazepine that in patients dysarthia, slurred rectal gel to treat
withdrawal probably potentiates hypersensitive to speech, tremor, no more than five
Muscle spasm the effects of GABA, drug or soy protein; transient amnesia, episodes per
Cardioversion depresses the CNS, in patients fatigue,ataxia, month and no
Adjunct treatment and suppresses the experiencing shock, headache, insomnia, more than one
for seizure disorders spread of seizure coma, or acute paradoxical anxiety, episode every 5
Status epilepticus, activity. alcohol hallucinations, minor days because
severe recurrent intoxication; in changes at EEG tolerance may
seizures pregnant women, patterns. develop.
Patients on stable especially in first CV: hypotension, CV When using oral
regimens of antiseptic trimester; and in collapse, bradycardia concentrate
drugs who need children younger EENT: diplopia, solution, dilute
diazepam intermittently than 6 months. blurred vision, dose just before
to control bouts of Diastat rectal gel nystagmus giving.
increase seizure activity. is contraindicated GI: nausea, Monitor
in patients with constipation, periodic hepatic,

acute angle-closure diarrhea with rectal renal, and
glaucoma. form hematopoietic
Use cautiously in GU: incontinence, function studies in
patients with liver urine retention patients receiving
or renal Hematologic: repeated or
impairment, neutropenia prolonged
depression, or Hepatic: jaundice therapy.
chronic open-angle Respiratory: Use of this drug
glaucoma. Use respiratory may lead to abuse
cautiously in depression, apnea and addiction.
elderly and Skin: rash Don’t withdraw
debilitated drug abruptly
patients. after long-term
use; withdrawal
symptoms may
occur.
Warn woman to
avoid use during
pregnancy.
PARACETAMOL 325mg/tab q4 Fever / mild pain Unknown. Thought Contraindicated Hematologic: Use liquid form
prn for fever to produce analgesia in patients hemolytic anemia, for children and
by bocking pain hypersensitive neutropenia, patients who have
impulses by to drug. leucopenia, difficulty
inhibiting synthesis Use cautiously in pancytopenia swallowing.
of prostaglandin in patients with Hepatic: jaundice In children
the CNS or other long term Metabolic: don’t exceed five
substances that alcohol use hypoglycemia doses in 24 hours.
sensitize pain because Skin: rash, urticaria
receptors to therapeutic
stimulation. The doses cause
drug may relieve hepatotoxicity in
fever through these patients.
central action in the
hypothalamic heat-

regulating center.

MUPIROCIN Treating impetigo, a Mupirocin Ointment Tell your doctor or Burning; pain; Inform pt. that:
OINTMENT type of skin infection. is an antibacterial. It pharmacist if you stinging.
kills sensitive have any medical If you have
bacteria by stopping conditions, Severe allergic any questions
the production of especially if any of reactions (rash; about
essential proteins the following apply hives; itching; Mupirocin
needed by the to you: difficulty breathing; Ointment,
bacteria to survive. tightness in the please talk
if you are chest; swelling of the with your
pregnant, mouth, face, lips, or doctor,
planning to tongue); severe pharmacist, or
become irritation; severe other health
pregnant, or itching. care provider.
are breast- Mupirocin
feeding Ointment is to
if you are be used only
taking any by the patient
prescription or for whom it is
nonprescriptio prescribed. Do
n medicine, not share it
herbal with other
preparation, or people.
dietary If your
supplement symptoms do
if you have not improve
allergies to or if they
medicines, become
foods, or other worse, check
substances with your
if you are doctor.
treating a burn
or open wound

if you have
kidney
problems

CLOXACILLIN Cloxacillin is used to Disrupt the synthesis If you have ever an allergic Take cloxacillin
treat many different of the peptidoglycan had an allergic reaction exactly as directed
types of infections layer of bacterial cell reaction to another (shortness of by your doctor. If
caused by walls. The penicillin or to a breath; closing of you do not
staphylococcus bacteria peptidoglycan layer cephalosporin, do your throat; understand these
("staph" infections). is important for cell not take cloxacillin hives; swelling of instructions, ask
wall structural unless your doctor your lips, face, or your pharmacist,
integrity. is aware of your tongue; rash; or nurse, or doctor
allergy and fainting); to explain them to
monitors your seizures; you.
therapy. severe watery
diarrhea and Take each dose
Before taking this abdominal with a full glass of
medication, tell cramps; or water. Take
your doctor if you unusual bleeding cloxacillin on an
have kidney or bruising. empty stomach 1
disease, stomach or hour before or 2
intestinal disease, hours after meals.
or infectious
mononucleosis. Do not drink juice
You may not be or carbonated
able to take beverages (soda)
cloxacillin because with your dose of
of an increased risk cloxacillin. These
of side effects. beverages will
decrease the
If you are a effectiveness of
diabetic, some the drug.
glucose urine tests
may give false Cloxacillin should

positive results be taken at evenly
while you are spaced intervals
taking cloxacillin. throughout the
day and night to
Cloxacillin is in the keep the level in
FDA pregnancy your blood high
category B. This enough to treat
means that it is the infection.
unlikely to harm an
unborn baby. Do Do not crush,
not, however, take chew, or open the
cloxacillin without capsules. Swallow
first talking to your them whole.
doctor if you are Shake the
pregnant. It is not suspension well
known whether before measuring
cloxacillin passes a dose. To ensure
into breast milk. Do that you get a
not take this correct dose,
medication without measure the
first talking to your liquid form of
doctor if you are cloxacillin with a
breast-feeding a dose-measuring
baby. spoon or cup, not
a regular
tablespoon. If you
do not have a
dose-measuring
device, ask your
pharmacist where
you can get one.
Take all of the
cloxacillin that has
been prescribed

for you even if
you begin to feel
better. Your
symptoms may
start to improve
before the
infection is
completely
treated. Store the
capsules at room
temperature and
store the
suspension in the
refrigerator for
longer use. The
suspension is
good for 14 days if
it is stored in the
refrigerator.
Throw away any
unused liquid
after this amount
of time.

ANATOMY AND PHYSIOLOGY

HUMAN HEART

The human heart is located in the thoracic
cavity, behind and slightly to the left of the
sternum. The heart is tilted so that its pointed end,
the apex, points downward toward the left hip,
while the broad end, the base, faces upward
toward the right shoulder. It is bordered laterally
by the lungs, anteriorly by the sternum, posteriorly
by the vertebral column, and inferiorly by the
diaphragm, making it a well-protected organ. The
heart weighs 7-15 ounces (200-425 grams) and is
approximately the size of the individual's fist. It is
approximately 12cm long, 9cm wide at the
broadest point, and 6cm thick. The apex is formed
by the tip of the left ventricle and is located at the
level of the 5th intercostals space. The base is
formed by the atria at the level of the second rib.

A protective sac called the pericardium
surrounds the heart. It consists of the following
layers:

Fibrous anchors the heart in the
mediastinum, surrounds roots of the
major blood vessels, prevents over-
distention, tough protective layer
Parietal lies directly beneath the fibrous
Visceral (Epicardium) lies beneath
parietal, attached to the heart itself

Pericardial fluid (up to 50ml) ultra filtrate of plasma provides a slippery surface for the movements of
the heart which prevents friction, located in pericardial cavity.

The wall of the heart consists of three layers:

The epicardium is the visceral layer of the serous pericardium.
The myocardium is the muscular part of the heart that consists of
contracting cardiac muscle and non-contracting Purkinje fibers that
conduct nerve impulses.
The endocardium is the thin, smooth, endothelial, inner lining of
the heart, which is continuous with the inner lining of the blood vessels.

CHAMBERS OF THE HEART

The heart consists of 2 muscular pumps known as
the left and right ventricles. The ventricles have 2
reservoirs called atria (left and right). Each ventricle acts to
serve different circulations. The right ventricle shifts
deoxygenated blood into the pulmonary circulation. Blood
enters the network of capillaries in the lungs and through a
process of diffusion carbon dioxide is lost and oxygen is
acquired; it then returns to the left atrium. The left
ventricle is the pump responsible for delivering blood into
the systemic circulation where it carries nutrients and
oxygen to the tissues. An exchange of nutrients and oxygen
for carbon dioxide and waste takes place; the waste rich
blood now returns to the right atrium

HEART VALVES

Atrioventricular (AV) valves lie between atria and
ventricles

• Tricuspid - on the right
• Mitral (bicuspid) - on the left
• Papillary muscles - attach to lower ventricular
walls and to chordae tendineae which in turn attach to
the AV valves. These keep the cusps of the AV valves from
being inverted into the atria when the ventricles contract.

Semilunar valves between ventricles and great vessels
exiting the heart

• Pulmonary - between RV and pulmonary trunk
• Aortic- between LV and aorta

As blood travels through the heart, it enters a total of four chambers and passes through four
valves. The two upper chambers, the right and left atria, are separated longitudinally by the interatrial
septum. The two lower chambers, the right and left ventricles, are the pumping machines of the heart
and are separated longitudinally by the interventricular septum. A valve follows each chamber and
prevents the blood from flowing backward into the chamber from which the blood originated.

Two additional passageways are present in the fetal heart:

The foramen ovale is an opening across the interatrial septum. It allows blood to bypass the
right ventricle and the pulmonary circuit, while the nonfunctional fetal lungs are still developing.

The opening, which closes at birth, leaves a shallow depression called the fossa ovalis in the
adult heart.
The ductus arteriosus is a connection between the pulmonary trunk and the aorta. Blood that
enters the right ventricle is pumped out through the pulmonary trunk. Although some blood
enters the pulmonary arteries (to provide oxygen and nutrients to the fetal lungs), most of the
blood moves directly into the aorta through the ductus arteriosus.

THE GREAT VESSELS OF THE HEART

Superior vena cava: brings
deoxygenated blood into the right atrium from
the head and upper body veins
Inferior vena cava: brings deoxygenated
blood from legs and lower torso into right
atrium
Pulmonary arteries (R and L): branch
from pulmonary trunk, carry deoxygenated
blood from the right ventricle into the lungs
Pulmonary veins (4): carry oxygenated
blood from lungs into the left atrium
Ascending Aorta: receives oxygenated
blood from the left ventricle and pumps it
throughout the body via arteries

BLOOD VESSELS

The central opening of a blood vessel, the lumen, is
surrounded by a wall consisting of three layers:

The tunica intima is the inner layer facing the
blood. It is composed of an innermost layer of
endothelium (simple squamous epithelium)
surrounded by variable amounts of connective
tissues. In arteries this layer is composed of an
elastic membrane lining and smooth
endothelium that is covered by elastic tissues.
The tunica media, the middle layer, is
composed of smooth muscle with variable
amounts of elastic fibers. This layer is thicker in
arteries than in vein.
The tunica adventitia, the outer layer, is
composed of connective tissue as well as
collagen and elastic fibres. These fibres allow
the arteries and veins to stretch to prevent
overexpansion due to the pressure that is
exerted on the walls by blood flow.

Blood vessels have three kinds that form a closed system of passageways:

Arteries carry blood away from the heart. The three
kinds of arteries are categorized by size and
function:
o Elastic arteries (conducting arteries) are the
largest arteries and include the aorta and
other nearby branches. The tunica media of
elastic arteries contains a large amount of
elastic connective tissue, which enables the
artery to expand as blood enters the lumen
from the contracting heart. During
relaxation of the heart, the elastic wall of
the artery recoils to its original position,
forcing blood forward and smoothing the
jerky discharge of blood from the heart.
o Muscular arteries (conducting arteries)
branch from elastic arteries and distribute blood the various body regions. Abundant
smooth muscle in the thick tunica media allows these arteries to regulate blood flow by
vasoconstriction (narrowing of the lumen) or vasodilation (widening of the lumen). Most
named arteries of the body are muscular arteries.
o Arterioles are small, nearly microscopic, blood vessels that branch from muscular
arteries. Most arterioles have all three tunics present in their walls, with considerable
smooth muscle in the tunica media. The smallest arterioles consist of endothelium
surrounded by a single layer of smooth muscle. Arterioles regulate the flow of blood
into capillaries by vasoconstriction and vasodilation.
Capillaries are microscopic blood vessels with extremely thin walls. Only the tunica intima is
present in these walls, and some walls consist exclusively of a single layer of endothelium.
Capillaries penetrate most body tissues with dense interweaving networks called capillary beds.
The thing walls of capillaries allow the diffusion of oxygen and nutrients out of the capillaries,
while allowing carbon dioxide and wastes into the capillaries.
o Metarterioles (precapillaries) are the blood vessels between arterioles and venules.
Although metarterioles pass through capillary beds with capillaries, they are not true
capillaries because metarterioles, like arterioles, have smooth muscle present in the
tunica media. The smooth muscle of a metarteriole allows it to acts as a shunt to
regulate blood flow into the true capillaries that branch from it. The thoroughfare
channel, the tail end of the metarteriole that connects to the venule, lacks smooth
muscle.
o True capillaries form the bulk of the capillary bed. They branch away from a
metarteriole at its arteriole end and return to merge with the metarteriole at its venule
end (thoroughfare channel).
o Some true capillaries connect directly from an arteriole to a metarteriole or venule.
Although the walls of true capillaries lack muscle fibers, they possess a ring of smooth
muscle called a precapillary sphincter where they emerge from the metarteriole. The
precapillary sphincter regulates blood flow through the capillary. There are three types
of true capillaries:

 Continuous capillaries have continuous, unbroken walls consisting of cells that
are connected by tight junctions. Most capillaries are of this type.
 Fenestrated capillaries have continuous walls between endothelial cells, but the
cells have numerous pores (fenestrations) that increase their permeability.
These capillaries are found in the kidneys, lining the small intestine, and in other
areas where a high transfer rate of substances into or out of the capillary is
required.
 Sinusoidal capillaries (sinusoids) have large gaps between endothelial cells that
permit the passage of blood cells. These capillaries are found in the bone
marrow, spleen, and liver.
Veins carry blood toward the heart. The three kinds of veins are listed here in the order that
they merge to form increasingly larger blood vessels:
o Postcapillary venules, the smallest veins, form when capillaries merge as they exit a
capillary bed. Much like capillaries, they are very porous, but with scattered smooth
muscle fibers in the tunica media.
o Venules form when postcapillary venules join. Although the walls of larger venules
contain all three layers, they are still porous enough to allow white blood cells to pass.
o Veins have walls with all three layers, but the tunica intima and tunica media are much
thinner than in similarly sized arteries. Few elastic or muscle fibers are present. The wall
consists of primarily of a well-developed tunica adventitia. Many veins, especially those
in the limbs, have valves, formed from folds of the tunica intima, which prevent the
backflow of blood.

Many regions of the body receive blood supplies from two or more arteries. The points where
these arteries merge are called arterial anastomoses. Arterial anastomoses allow tissues to receive
blood even after one of the arteries supplying blood has been blocked.

BLOOD FLOW THROUGH THE HEART

The heart has four chambers that pump
blood. The chambers are called the right atrium,
right ventricle, left atrium, and left ventricle. The
right and left sides of the heart are separated by
muscular wall called the septum. This prevents
blood without oxygen from mixing with
oxygenated blood. The heart also has valves that
separate the chambers and connect to major blood
vessels.

Blood flows from the body into the right
atrium. The blood on the right side of the heart
had been used by the body and is deoxygenated or
oxygen-poor.

The deoxygenated blood flows from the
right atrium through the tricuspid valve to the
right ventricle.

From the right ventricle, blood is pumped
through the pulmonary valve into the blood vessel
that goes to the lungs. This blood then picks up
oxygen becomes oxygenated or oxygen-rich.

Oxygenated blood flows from the lungs
through blood vessels back to the hearts left
atrium.

From the left atrium, blood goes through the mitral valve and into the left ventricle.

The left ventricle pumps blood through the aortic valve to a major blood vessel called aorta and
into systemic flow.

The blood delivers oxygen to the body, the returns through veins to the right atrium and repeats
the blood flow cycle.

BLOOD SUPPLY TO THE HEART

The coronary circulation consists of blood vessels, called
coronary arteries, which supply oxygen and nutrients to the
tissues of the heart. Blood entering the chambers of the heart
cannot provide this service because the endocardium is too
thick for effective diffusion (and only the left side of the heart
contains oxygenated blood). Instead, the following two arteries
that arise from the aorta and encircle the heart in the
artioventricular groove provide this function:

The left coronary artery has the following two
branches: The anterior interventricular artery (left anterior
descending, or LAD, artery) and the circumflex artery.
The right coronary artery has the following two
branches: The posterior interventricular artery and the
marginal artery.

The blood from the coronary circulation returns to the right atrium by way of an enlarged blood
vessel, the coronary sinus. Three veins, the great cardiac vein, the middle cardiac vein, and the small
cardiac vein, feed the coronary sinus.

CONDUCTION SYSTEM

1. Sinoatrial (SA)node - pacemaker, located at the
surface of the right atrium, impulse causes both atria to
contract (rate 60-100 BPM); a conduction pathway called
Bachman's bundle runs from right to left atrium allowing for
simultaneous atrial contractions. SA node sends impulse to
the AV node via the anterior, medial and posterior
internodal pathways.

2. Atrioventricular (AV) node - (rate 40-60 BPM) last
part of atria to be depolarized, sends impulse down the:

3. Bundle of His- distributes action potential over
medial surfaces of the ventricles (rate 20-40 BPM) runs to
the top of the interventricular septum to the:

4. Right and left bundle branches - Actual contraction
stimulated by conductive myofibers called Purkinje fibers
that pass into the fibers of the myocardium of the ventricles.

Case study of TOF

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Case study of TOF

Similar to Case study of TOF (20)

Recently uploaded

Recently uploaded (20)

Case study of TOF