Nursing 2514

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Nursing 2514

• Cardiac Anatomy Physiology
• with
• Diagnostic Tests

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Heart Location

• Located slightly to the left of midline

• Approximately the size of your fist
• Surrounded by
• Sternum Vertebrae
• Lungs Major blood vessels

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Layers of Heart

• Endocardium
• Thin innermost layer
• Myocardium
• Muscular layer
• Epicardium
• Outer serous membrane
• Pericardium
• Sac that covers the heart

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Coronary arteries

• Right coronary artery
• Left coronary Arteries
• 2 main branches
• anterior descending
• circumflex

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Coronary Blood SupplyArterial

• Sinuses of Valsalva
• Open to right Left coronary arteries
• Blood flow occurs during diastole
• Right coronary artery
• Right atrium ventricle
• Portion of posterior wall of left ventricle
• 90 of population AV Node
• Left coronary arteries
• Left anterior descending artery
• Left circumflex artery
• left atrium ventricle

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Coronary Blood SupplyVenous

• Coronary veins are parallel to the arteries
• System drains into the coronary sinus
• Empties into right atrium near inferior vena cava

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Heart is a hollow muscular organ

• Four interior chambers
• Superior chambers
• Atrium
• For receiving blood
• Inferior chambers
• Ventricles
• For propelling blood

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Function

• Two separate pumps
• Right sided
• Transports unoxygenated blood
• Pumps to pulmonary system
• Left Sided
• Transports oxygenated blood
• Pumps to entire body

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Heart valves

• Heart valves
• Prevent backflow of blood into atria
• Attached with chordae tendineae to papillary
  muscles of ventricles
• Prevents eversion of valve

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Heart valves

• Heart valves
• Right Heart
• Tricuspid valve
• Between right atria ventricle
• Left Heart
• Mitral valve
• Between left atria ventricle

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Heart Sounds
S1 is the Lub Sound produces as the result of
the heart valves closing
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Valves of Heart

• Valves to Major Vessels
• Right heart
• Pulmonic
• Located between right ventricle and pulmonary
  artery
• Left Heart
• Aortic
• Located between left ventricle and aorta

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Heart Sounds

• S2
• Is the Dub
• Sound created when the major vessel valves close

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Heart Sounds

• S3 heart sound is heard after S2
• Caused by ventricular filling
• Associated with
• Left ventricular failure
• Mitral valve regurgitation

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Heart Sounds

• S4 heart sound is heard before S1
• Caused by atrial contraction
• Associated with
• Coronary artery disease
• Left ventricular hypertrophy
• Aortic stenosis

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Problem with Valves

• Would expect to hear murmurs in patients with
  valve problems.
• Patients with valve disease or heart murmurs may
  need to have prophylactic antibiotics before
  major dental work.

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Problem with Valves

• Patients with prosthetic valves may be at risk
  for infective endocarditis from just having their
  teeth cleaned.

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Think about it.

• After valve replacement if a patient has sudden
  calf pain the leg is pale cool with no
  pulses, what would you expect what would you do
  to the patients position in bed?

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Circulation of Blood Through the Body

• Unoxygenated blood
• Capillaries
• Veins
• Vena cava
• Right atrium
• Tricuspid valve
• Right ventricle
• Pulmonic valve
• Pulmonary Artery
• Lungs

• Oxygenated blood
• Lungs
• Pulmonary vein
• Left atria
• Mitral valve
• Left ventricle
• Aortic valve
• Aorta
• Arteries
• Capillaries

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Blood vessels

• Arteries
• Blood flows away from heart
• Large thick walled vessels
• Containing smooth muscle
• Allows for vasoconstriction or dilation

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Blood vessels

• Veins
• Blood flows toward heart
• Large diameter
• Thin walled
• Contain semi lunar valves to prevent back flow of
  blood
• Capillaries
• Thin walled (one cell)
• Allows for transport of
• nutrients waste
• Oxygen carbon dioxide

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Pulse Sites
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Cardiac Muscle Properties

• Automaticity
• Performed without conscious control
• Heart rate
• Contractility
• Ability to shorten in response to stimulus.

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Cardiac Muscle Properties

• Conductivity
• Ability/capacity to transmit electrical impulses.
• Excitability
• Readiness to respond to a stimulus
  irritability.

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Cardiac Muscle Properties

• Refractory
• The period of depolarization and re-polarization
  of the cell membrane after excitation.
• During the first period (absolute refractory
  period), the nerve or muscle fiber cannot respond
  to a second stimulus. QRS complex.
• During the relative refractory period, it can
  respond only to a strong stimulus. T wave.

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Cardiac Muscle Properties

• NOTE Any property of the cardiac muscle can be
• Positive (potentates, fosters, activates)
• Negative (negates, inhibits, blocks, prevents).

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Cardiac Muscle

• Automaticity Heart rate.
• Chronotropic ( or -).
• Rate, rhythm, function of heart.
• Spontaneous, repetitive depolarization

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Cardiac Muscle

• Automaticity
• Heart rate.
• Specialized cells in the SA node, parts of the
  atria, AV node His-Purkinje system are able to
  discharge spontaneously.
• Normal pacemeker of the heart SA node, right
  atrium.
• Discharges 60-100 times per minute.

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Cardiac Muscle

• Automaticity
• Secondary pacemakers that can take over
• AV node (40-60 times/min.) or
• The His-Purkinje system (30-40 times/min.).
• Early or late escaping triggered beats include
  ectopic focus in atria, ventricles or AV nodal
  area. May present as a run of irregular beats,
  replacing the NSR (normal sinus rhythm).

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Cardiac Muscle

• Contractility
• Inotropic affecting the force of muscular
  contractions ( or -) Contracts as a whole unit
  simultaneously, efficiently, not randomly.
• Contraction of heart muscle causes heart to beat.

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Cardiac Muscle, cont.

• Conductivity
• Dromotropic. Orderly.
• Electrical impulses sent.

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Cardiac Muscle

• Excitability
• Impulse started by a pacemaker conducted to the
  entire heart chamber.
• Allows heart muscle to be depolarized by a
  stimulus, an important part of the transmission
  of impulse from one fiber to another.
• Determined by length of time after depolarization
  that the tissues can be restimulated.

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Cardiac Muscle

• Refractory Phase recovery period after
  stimulation (absolute or relative).

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Preload

• How forcefully ventricles contract in systole.
• Amount of pressure on the left ventricles wall
  just before it contracts.
• Filling of ventricles at end of diastole
  (resting).

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Afterload

• Amount of pressure in the aorta that the
  ventricle must overcome to pump blood into
  systemic circulation.
• Resistance heart has to overcome to efficiently
  pump blood to peripheral systemic circulation.
• Cant measure directly wedge pressures (left
  sided heart pressures) CVP.

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Stroke Volume

• Stroke Volume amount of blood heart will
  eject/min.
• Affected by preload, afterload contractibility.
• If you increase the heart rate, the heart cant
  get rid of all the blood so the SV goes down.
• In PVD atherosclerosis there is increased
  pressure in the aorta from resistance coming out.

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Cardiac Output

• Cardiac Output volume ejected by the ventricles
  with each beat.
• Affected by preload amount of blood in
  ventricles at end of diastole before next
  contraction.
• CO Heart rate (beats/min.) X SV (volume/beat)
  5-8 Liters/min.
• Example 70 beats/min. X 60-80ml/beat 4200 to
  5600 cc (4.2 5.6 Liters)

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SV and CO

• Right sided heart problems
• Increased preload
• Hepatomegaly
• Increased JVD, etc.
• Pulmonary edema Roman crucifixions.
• Systolic ejection (resting/filling) power is
  relative to volume.
• Review valsalvas impact on the heart for
  patients with compromised cardiac conditions.

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Cardiac History

• Elevated B/P
• Skin turgor
• Coronary artery condition
• Meds
• Surgeries
• Lifestyle
• Smoker
• Alcohol consumption
• Exercise
• Sleep

• Chest pain
• Stress
• Psychosocial
• physical
• Gender
• Age
• Menopausal

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Changes with Age

• Weaker intimal linings of vascular circulation
• Atherosclerosis
• Elevated B/P
• Decreased perfusion

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Nursing 2514

• Cardiac Diagnostic Tests

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Cardio-vascular Disorders Diagnostics

• Blood work
• Triglycerides (HDL/LDL ratios).
• Cardiac enzymes CPK, LDH, troponin.
• Coagulation studies (PT, PTT, INR)
• Digoxin level.

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Cardio-vascular Disorders Diagnostics

• Blood work
• Cholesterol
• Lipoproteins
• Serum electrolytes
• Liver function tests
• Arterial blood gases

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Diagnostics - Enzymes

• Iso-enzyme subcategories specify where injury is
  located.
• LDH (N 110-120) heart, liver, kidneys.
• There are 5.
• LDH 1 2 normally 2 is gt 1 but in an MI, 1 is
  gt2.
• CPK
• Mm (regular striated muscle)
• Mb (brain)
• BB (heart) gt5 is MI.
• Starts to rise 3-6 hours after injury.
• Peaks 12-24 hours and stays elevated 3-4 days.

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Enzymes, cont.

• Troponin enzyme changes in heart.
• Rises in 2-4 hours stays elevated 8-9 days.
• Usually gt1.5 is MI.

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Cardio-vascular Disorders Diagnostics

• 12 Lead EKG possible changes R/O MI.
• Ischemia inverted T wave. Repolarization is
  late in leads II, III AVF depressed ST.
• MI or injury Q wave or ST elevation.
• Elevated troponin CK enzyme
• Chest X Ray

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Cardio-vascular Disorders Diagnostics

• Halter Monitor
• Phonocardiogram.
• Echocardiogram.
• Doppler flow studies

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Cardio-vascular Disorders Diagnostics

• MRI
• Nuclear Imaging cardiology (PET, MUGA, thallium
  scans, etc.)
• Pharmacological stress testing persantine,
  dobutamine.
• For those who cant do physical testing
  (amputees, etc.)

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Cardio-vascular Disorders Diagnostics

• Mechanical stress testing treadmill.
• Radioactive drugs (isotope scan)
• TEE (trans esophageal echocardiogram sound
  waves).

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Cardio-vascular Disorders Diagnostics

• Angiography right/left coronary arteries
  branches.
• Invasive scope down back side of heart.
• EP (electro physiology) studies in lab with or
  without ablation.
• Note Some of the stress testing may
  precipitate a heart attack or irregular rhythm.

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Cardiac Catheterization

• Sign consent. Allergic to dye?
• Take shower.
• NPO 6-8 hours.

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Cardiac Catheterization

• Catheterized through groin or brachial artery
  (arm).
• Inject dye through coronary arteries
  chambers/valves.
• Hydrate well during procedure.
• May give benedryl or steroids if allergic
  reaction.

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Cardiac Catheterization

• Post procedure
• Lie flat about 6 hours, keep legs or arm
  straight.
• Vital signs every 15/30/60 minutes.
• Frequent checking for bleeding at site.
• Bleeding versus oozing (gushing). Manual pressure
  for latter.
• Dressing versus 10 lb. Sandbag or FemStop
  occlusion.

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Cardiac Catheterization

• Post procedure
• Frequent check of pulses distally
• Check sensorium/ LOC
• Cardiac monitoring
• Pain check meds
• Discharge continue to check for bleeding
  circulation

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Clip art work from

• Mosby s Electronic Image Collection
• Life Art
• Microsoft Clip Art
• Memory Notebook of Nursing