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MEDICAL-SURGICAL NURSING PROF. JONAH CORPUZ LECTURE \ FIRST SEMESTER COLLEGE OF NURSING BATCH 2026 ANATOMY OF CARDIOVASCULAR Pericarditis...

MEDICAL-SURGICAL NURSING PROF. JONAH CORPUZ LECTURE \ FIRST SEMESTER COLLEGE OF NURSING BATCH 2026 ANATOMY OF CARDIOVASCULAR Pericarditis - inflammation of the pericardium often results SYSTEM to the decrease of the amount of fluid - causes the pericardial layers to bind and stick The Heart pumps blood to each other, forming painful adhesions that Blood vessels allow blood to circulate to all parts of the interfere with heart movement. body. The major function is transportation using blood as the transport THE HEART WALL vehicle 1. to deliver oxygen and nutrients and cell wastes, 1. Epicardium hormones and many other substances vital for the body - Outside layer homeostasis - This layer is the parietal pericardium 2. to remove carbon dioxide and other waste products - Connective tissue layer 2. Myocardium - Middle layer HEART - Mostly cardiac muscle - The layer that actually contract - The heart located in the thorax between the lungs 3. Endocardium - Pointed apex directed toward left hip and rest of the - Inner layer diaphragm at the level of the 5th ICS - Endothelium that lines the heart chamber and - About the size of your fist continuous to the lining of the blood vessels - Hollow cone shaped weighs less than a pound MEDIASTINUM - middle cavity of the thorax that enclosed the heart inferiorly THE HEART COVERINGS Pericardium - a double sac of serous membrane Visceral pericardium (thin epicardium) - Next to heart part of the heart wall Parietal pericardium (fibrous pericardium) - Outside layer and protect the heart and The Heart: Chambers and Associated Great anchors the it to the surrounding structures Serous fluid fills the space between the layers of Vessels pericardium - Normally, a small volume (≈0.25 ml/kg) of Right and left side act as separate pumps serous fluid lies between the outer fibrous Four chambers (parietal) pericardial layer and the serous Atria visceral pericardium or epicardium. - Receiving chambers - Right atrium - Excess, abnormal fluid within this space - Left atrium (pericardial effusion) is a common disorder Ventricles that has a variety of causes - Discharging chambers - Actual pumping station of the heart HOMEOSTATIC IMBALANCE - Right ventricle (form the anterior surface) - Left ventricle (forms the apex) Hennessy Fabiculana  INTERVENTRICULAR or INTERATRIAL Valves open as blood is pumped through Held in place by chordae tendineae (“heart strings”) - is the septum that (TV) divides the heart Close to prevent backflow longitudinally. The Heart: Associated Great Vessels Aorta - Leaves left BLOOD CIRCULATION ventricle Pulmonary arteries Function as double pump - Leave right The Right side as pulmonary circuit ventricle pump- receives unoxygenated blood Vena cava from the veins through the large - Enters right SUPERIOR VENAE CAVAE passing atrium the RA then RV and pumps it to the Pulmonary veins PULMONARY ARTERIES, which (four) carry blood to the lungs, where O2 is - Enter left pick up and CO2 is unloaded.The atrium oxygen-rich blood returned to the left side of the heart via the four HOMEOSTATIC IMBALANCE PULMONARY VEINS. The circulation from the Valvular Stenosis R side- to the lungs and back to the L - Heart valve disease or narrowed valve occurs side is called PULMONARY when there is narrowing, stiffening and CIRCULATION thickening and blockage, the defective heart will work hard to pump - The blood that returns from the left side is pumped blood. out of the heart into the AORTA to the systemic Endocarditis branch to essentially supply the body tissues. - bacterial infection of the Unoxygenated blood from the tissues back to the endocardium. RA. This 2nd circuit from the Left side—to the body tissue– Right side of the heart is called the SYSTEMIC CIRCULATION Coronary circulation - Blood in the heart The Heart: Valves chambers does not nourish the myocardium - The heart has its own nourishing circulatory Allow blood to flow in only one direction through the system heart chambers Cardiac arteries FOUR VALVES - The arteries of the heart 1st set of valves Cardiac veins - Atrioventricular valves (AV valves) - Veins of the heart - Located between atria and ventricles Note: CV blood empties into the right atrium via the Tricuspid valve (right) coronary sinus Bicuspid valve (left) Mitral Valve ANGINA PECTORIS 2nd set of valves - Semilunar valves between ventricle and artery Crushing Chest Pain - Pulmonary semilunar valve - when the heart beats rapidly the myocardium - Aortic semilunar valve receives inadequate blood supply because of the relaxation periods are shortened causing the part deprived of oxygen (Warning sign) The Heart: Function of the Valves Infarct Hennessy Shaina Fabiculana  - from when the angina is prolonged, the ischemic heart cells will die resulting in MYOCARDIAL INFARCTION (MI) commonly HEART BLOCK called “heart attack”. - damage of the AV node can partially or totally release PHYSIOLOGY OF HEART the ventricles out of control from the SA node, thus the ventricles begin to beats on their own rate, much slower The heart beats or contract in all the time. The blood continuous round trip In 1 day, it pushes the body’s 6 quarts or so of blood ISCHEMIA (6 L) through the blood vessels over 1000 x, meaning it actually pumps out 6000 quarts of blood in a - lack of adequate blood supply to the heart muscle that single day! will lead to, FIBRILLATION, a rapid , uncoordinated shuddering of the heart muscle—makes the heart totally useless—death (heart attack) The Heart: Conduction System TACHYCARDIA - Heart muscle cells - rapid heart beat over 100 beats/min contract, without BRADYCARDIA nerve impulses, in - the heart rate is very slow, less than 60 beats /min. a regular, continuous way - Cardiac muscle can The Heart: Cardiac Cycle beat independently - atrial cells beats Atria contract simultaneously 60/minutes Atria relax, then ventricles contract - ventricular cells beat -20-40/min. Systole = contraction Diastole = relaxation 2 systems that regulates the Cardiac activity 1. Involves the nerve and the ANS CARDIAC CYCLE 2. Intrinsic conduction system (nodal system) - events of one complete heartbeat - built in into the heart tissue and sets its basic rhythm Mid-to-late diastole - cause the heart muscle depolarization and - Blood flows into ventricle only one direction Ventricular systole - enforces a contraction rate of 75/minute - Blood pressure builds before ventricle (resting heart rates),thus the heartbeat is coordinated Early diastole - atria finish re-filling, ventricular pressure is low Sinoatrial node (located at the RA) - Called the (natural) Pacemaker it starts the 2 distinct sound during each cycle-the HEART SOUND heartbeat and set the whole pace of the heart “Lub (closing of the AV valves and Dub” (semilunar close at the end of systole) Atrioventricular node - junction of the atria and ventricle Atrioventricular bundle MURMURS Bundle branches - both located at the interventricular septum - abnormal or unusual heart sound (valve problems) Purkinje fibers - there is an obstruction common in young children and - spread within the muscle of the ventricle walls some elderly (normal because their heart wall is thin) The Heart: Cardiac Output HEART CONTRACTIONS CARDIAC OUTPUT (CO) Contraction is initiated - Amount of blood pumped by each side of the heart in by the sinoatrial node one minute Sequential stimulation - CO is the product of = (heart rate [HR]) x (stroke occurs at other auto volume [SV]) rhythmic cells Hennessy Shaina Fabiculana STROKE VOLUME left side is unable to eject blood returning to - Volume of blood pumped by each ventricle with each the systemic circulation heartbeat - blood vessels in the heart with blood, lungs - Average CO= HR (75 bpm) x SV (70 ml/beat) become swollen, pressure increases, fluid CO =5250 ml/min (varies w/ the demand of the leaks into the circulation causing body) ( combination of HR and SV) PULMONARY EDEMA (untreated—person suffocates) The Heart: Regulation of Heart Rate Peripheral Congestion - the right side of the heart fails occurs as blood Stroke volume usually remains relatively constant backs up in the systemic circulation. - Edema is noticeable in the distal part of the Starling’s law of the heart body (feet , ankles and fingers become - the more that the swollen and puffy cardiac muscle is - stretched, the stronger Failure one side of the heart put strain in the other side that the contraction will make the whole heart fails - States that the stroke volume of the heart BLOOD VESSEL increases in response to an increased blood - A form of closed volume filling the heart (diastolic vol. ) when all the system that other factors remain constant circulates blood to the tissues Venous return and back. - important factor stretching the heart muscle (“makes rounds”) Changing heart rate is the most common way to change cardiac output TYPES OF BLOOD Increased heart rate VESSELS - Sympathetic nervous system - Arteries - Crisis - Arterioles - Low blood pressure - Capillaries - Hormones - Venules - Epinephrine - Veins - Thyroxine - Exercise - Decreased blood volume Blood Vessel: Anatomy Decreased heart rate Three layers (tunics) - Parasympathetic nervous system Tunic intima (inner) - High blood pressure or blood volume - Endothelium - Decreased venous return - Decreases friction as blood flows through the vessels Congestive Heart Failure Tunic media (middle) - pumping efficiency is depressed so that - Smooth muscle circulation is inadequate - Controlled by sympathetic nervous system - progressive condition that reflects the (constrict/dilates pressure) weakening of the heart by Tunic externa (outer) CORONARY ATHEROSCLEROSIS - Mostly fibrous connective tissue - clogging of the coronary vessels with fatty - To support and protect the vessels. build up WALLS OF ARTERIES Pulmonary Congestion- - left sided failure. The right side is - are the thickest and continuously propel blood to the lungs but the strong, much heavier, closer to Hennessy Shaina Fabiculana  the pumping action of the heart, pregnant. in pooling of blood in the feet and - able to expand and stretchy enough to take continuous legs there is an insufficient venous return changes resulting from inactivity or pressure from the veins Differences between Blood Vessel Type THROMBOPHLEBITIS - inflammation of Lumens of veins the vein that - Are larger far from the heart in the circulatory results when a pathway, pressure tend to be low all the time. clot forms in a - Have thinner walls. vessel with poor - Ensure blood returning to the heart (venous circulation. return) equals amount being pumped out (Cardiac output) - They have valves to prevent blood flow. - Skeletal muscle “milks” blood in veins PULMONARY EMBOLISM toward the heart - is clot detachment and goes to the Differences between Blood circulation which is a life Walls of capillaries - are only one cell layer (tunica intima) - thick to allow for exchanges between blood and tissue easier - Formed interweaving networks called “capillary beds” GROSS ANATOMY of BLOOD VESSELS COMPOSED 2 VESSELS Major Arteries and the Systemic Circulation 1. Vascular shunt -connects the arteriole and the venule 2. True capillaries number 10 to 100/CB- the actual AORTA exchange vessels - Is the largest artery of the body that carries oxygenated blood Oxygen and nutrients cross to cells Carbon dioxide and metabolic waste products cross into blood Parts (named according for their location and shape) Movement of Blood Through Vessels Ascending Aorta - spring upward from the left ventricle of the heart Most arterial blood is Aortic Arch pumped by the heart - arch's to the left Veins use the milking action of muscles to help Thoracic Aorta move blood - downward through the thorax Abdominal Aorta - passes the diaphragm to the abdominopelvic cavity Major Arteries of Systemic Circulation Arterial Branches of the Aortic Arch Carotid artery HOMEOSTATIC IMBALANCE - major artery that supply blood to the brain, neck and face Varicose veins - common for Subclavian artery people who stand - supply blood to the posterior cerebral for a long period circulation cerebellum ,neck, upper limbs, and of time, obese, ant and superior chest wall Hennessy Shaina Fabiculana  Vertebral Artery Radial and Ulnar Veins - arms Axillary Artery Axillary veins- axillary region Brachial artery Cephalic vein Radial artery - Lateral aspect of the arms and toes into the Ulnar artery axillary region Arterial Branches of the Thoracic Aorta Basilic veins - medial aspect of the arm to medical aspect of Intercostal arteries the brachial vein - supply the muscle of the thorax wall Subclavian vein Bronchial Arteries - receives venous blood from the arm through - supply the lungs axillary vein and from the skin and muscles through the head external jugular vein. Esophageal arteries - supply the esophagus PULMONARY VEIN - the only vein that carries oxygenated blood Phrenic nerves - - Diaphragm Arterial Supply of the Brain and the Circle of Wilis PULMONARY ARTERY - the only artery that carries unoxygenated blood Internal Carotid Artery - run through the neck and enter the skull Arterial branches of the Abdominal Aorta through the temporal bone. Anterior and Middle cerebral arteries 3 branches of Celiac trunk - supply most of the cerebrum Vertebral arteries 1. Gastric artery- stomach - pass upward from the subclavian 2. Splenic artery -spleen Basilar artery 3. Common hepatic artery- supplies the liver - serves the brain steam and cerebellum Posterior cerebral arteries Superior mesenteric - supply posterior part of the cerebrum - supply most of the small intestine Circle of Willis Renal artery - complete circle of - severe kidney connecting blood vessels that Gonadal artery surrounds the base - supply the Ovarian arteries (female) testicular of the brain arteries (male) - protects the brain by providing more route Femoral artery for blood to reach the - Seerne the thigh brain tissue in case of clot or impaired Popliteal Artery blood flow - FA become at the knee Hepatic Portal Circulation Dorsalis pedis - Supply the dorsum of the foot Hepatic Portal Vein- - the veins of the hepatic circulation that drains Major Veins of Systemic Circulation the digestive organs, spleen, and pancreas and deliver to the blood. Superior Vena Cava - Blood enters the heart into the superior vena Inferior mesenteric vein cava and drains to the lower body empty to the - draining the terminal part of the large intestine Inferior vena cava that carries unoxygenated blood. Splenic nerve- Hennessy Shaina Fabiculana  - drains the spleen pancreas and left side of the - Measurements by health professionals are made on the stomach pressure in large arteries Superior mesenteric vein Systolic - drains the small intestine and the 1st part of - pressure at the peak of ventricular the colon contraction Diastolic - pressure when ventricles relax Fetal Circulation - Pressure in blood vessels decreases as the distance away from the heart increases - All nutrients, excretory and gas exchange occurs through the placenta - Nutrient and oxygen from the mother’s blood into the fetal blood. - Fetal waste move in the opposite direction - The umbilical cord contains 3 BLOOD VESSELS Blood Pressure: Effects of Factors 1 umbilical veins - (carries blood rich in nutrients and oxygen to Neutral factors the fetus) - Parasympathetic- little or no effect 2 umbilical arteries - Autonomic nervous system adjustments - (carry Carbon dioxide and debris from the (sympathetic division) (causes placenta vasoconstriction) Dactus venosus Renal Factors - entrance of the blood going to the inferior - Regulation by altering blood volume vena cava. Renin- hormonal control Foramen Ovale Temperature - where blood entering the RA is shunted and - Heat has a vasodilation effect (speed up directed circulation) Ductus arteriosus- 2nd shunt where the short vessel and - Cold has a vasoconstricting effect connects the aorta and pulmonary trunk Chemicals - Various substances can cause increases or Physiology of Circulation decreases Diet Vital Signs - good indication of the efficiency of person’s circulatory system Pulse - pressure wave of blood FACTORS - Monitored at “pressure points” where pulse is easily palpated BLOOD PRESSURE Hennessy Shaina Fabiculana  Variations in Blood Pressure Human normal range is variable Normal - 140–110 mm Hg systolic - 80–75 mm Hg diastolic Hypotension Low systolic (below 110 mm HG) Often associated with illness - Hypertension High systolic (above 140 mm HG) - Can be dangerous if it is chronic Orthostatic Hypotension - elderly people may experience temporary low BP and dizziness when they rise suddenly from Developmental Aspects of the Cardiovascular reclining to sitting position. System Circulatory shock /A simple “tube heart” develops in the embryo and pumps by the fourth week - condition in which blood vessels are in adequately The heart becomes a four- chambered organ by the filled and blood cannot circulate properly due to end of seven weeks blood loss. Few structural changes occur after the seventh week Capillary exchange Capillary diffuse trough intervening space filled with interstitial fluid (tissue fluid) - Substances exchanged due to concentration gradients - Oxygen and nutrients leave the blood - Carbon dioxide and other wastes leave the cells Capillary Exchange: Mechanisms Direct diffusion across plasma membranes Endocytosis or exocytosis Some capillaries have gaps (intercellular clefts) - Plasma membrane not joined by tight junctions - Fenestrations of some capillaries - Fenestrations- pores Hennessy Shaina Fabiculana  Demographic data - Age COURSE OUTLINE: MIDTERMS - Gender 1. Coronary Artery Disease - Ethnic 2. Angina Pectoris NOTE: The nurse conveys sensitivity to the cultural background 3. Hematologic System and religious practices to the patient Height Weight Care of clients with problems in - Oxygenation Current height and usual weight (if there has been a (Cardiovascular, Peripheral Vascular, Lymphatic recent weight loss or gaining) and — Blood Disorders) COMMON SIGNS AND SYMPTOMS OF CVD WITH RESPONSES TO ALTERED TISSUE PERFUSION RELATED MEDICAL DIAGNOSIS NOTE: Nervous system and Cardiovascular system are the 1. Chest pain or discomfort major affected - Angina pectoris, myocardial infraction or ACS, VHD FACTORS OF FREQUENCY AND EXTENT 2. Shortness of breath or dyspnea - MI or ACS cardiogenic shock, LV, Heart 1. Severity of the patient's symptoms Disease, HF - Difficulty of breathing and chest pain 3. Peripheral Edema and weight gain 2. Presence of risk factors - Right ventricular failure - Contribute in signs and symptoms - Abdominal distention due to enlarged 3. Practice setting spleen and liver or ascites (HF) - Known of the nurses to assess TERMS 4. Purpose of the assessment CARDIOVASCULAR DISEASE (CVD) NOTE: A patient who is admitted at the Emergency Room have General term for conditions affecting the heart of blood different assessment in any unit of the hospital vessels. It usually associated with build up fatty deposit inside the arteries (atherosclerosis) and an increase HEALTH HISTORY risk of blood clots. Major barriers to seek medical treatment CORONARY ARTERY DISEASE (CAD) 1. Lack of knowledge about the symptoms of heart Disease caused by plaque buildup in the wall of the disease arteries that supply blood to heart called coronary 2. Attributing symptoms to a benign source arteries. 3. Denying symptoms significance Signs and symptoms experience by patient with: 4. Feeling embarrassed about having the symptoms ACUTE CORONARY SYNDROME (ACS) Valvular Heart Disease (VHD) NOTE: Proper response of the family and patient during inquiry will help the nurse individualized the plan for patient and family CORONARY ARTERY DISEASE (CAD) education ACUTE CORONARY SYNDROME (ACS) Major supply of blood and nourishment Patient experiencing an acute condition Which describe any condition characterized by Use few specific question about the onset and severity signs and symptoms of sudden myocardial of chest discomfort ischemia a sudden reduction in blood flow to Associated symptoms the heart allergies Observes the The term ACS was adopted because it was believed to Patient's general appearance more clearly reflect the disease progression associated Evaluates hemodynamic status with myocardial ischemia. NOTE: Once the condition of the patient stabilizes, a more NOTE: Cardiovascular Disease (CVD) are related to extensive history taking can be obtained dysrhythmias and conduction problems; CAD to other disorders have many signs and symptoms in common. If stable patient A complete health history obtained during the initial Therefore, the nurse must be skillful at recognizing so the patient contact (especially the relatives) will be given lifesaving care. Hennessy Shaina Fabiculana  4. Palpitations There is poor correlation between the location of tachycardia from a variety of cause: chest discomfort and its source. - ACS The client may have more than one clinical condition - Caffeine or other stimulants occurring simultaneously - Electrolyte imbalance In a client with a history of CAD, the chest discomfort - Stress should be assumed to be secondary to ischemia until - Vascular heart disease proven otherwise. - Ventricular aneurysm General Appearance and Cognition 5. Unusual Fatigue - Sometimes referred to a vital exhaustion LEVEL OF CONSCIOUSNESS - Earliest symptoms associated with several Alert cardiovascular like: Lethargic - ACS Stupor - HF Comatose - Valvular heart disease - Characterized by feeling unusual MENTAL STATUS tired or fatigue, irritable and Oriented dejected Place Time PHYSICAL ASSESSMENT Coherence Effectiveness of the heart as a pump SIGNS OF DISTRESS Filling volumes and pressure Pain or discomfort Cardiac output SOB Compensatory mechanisms Anxiety DETERMINE OBESITY CHEST PAIN AND CHEST DISCOMFORT Weight Height - Where is your pain (ask patient to point to location on Calculated BMI chest) (can b a result from number of causes) Waist circumference - What does the pain feel like? (pressure, heaviness, burning) BMI greater than 30 kg/m2 - How severe is it on a scale of 0 to 10? (severity or Waist circumference: duration does not predict the seriousness of its cause. ○ Male greater than 40 inches - What causes the pain? (exertion, stress) ○ Female - greater than 35x inches - Does anything relieve it? ( rest, nitroglycerin) Placing patient at risk of CAD - Does it spread to your arms, neck, jaw, shoulders or back? LEVEL OF CONSCIOUSNESS - How long does the pain last? - Do you have any additional symptoms? (shortness of breath, palpitations, dizziness, sweating) Level Technique Abnormal - Response NOTE: Chest pain is not a determinant in the severity of condition Alert Speak to the patient Normal response: Example: In a normal tone of Aware of time, Esophageal spasm voice. An alert patient place and people. Myocardial infarction opens the eyes, looks at you, and responds fully and CONSIDERATIONS IN ASSESSING PATIENTS appropriately 2 stimuli (arousal Intact) WITH CARDIAC SYMPTOMS: Lethargic Speak to the patient A lethargic patient Women are more likely to present with atypical In a loud voice. For appears drowsy symptoms of MI than are men example, call the but open the eyes Elderly people and those with diabetes may not have patient’s name or ask and looks at you, pain with angina or MI because of neuropathies. “How are you?” responds to Fatigue and shortness of breath may be a questions, and then falls asleep. predominant symptoms in these patients Hennessy Shaina Fabiculana  2. Pallor Obtunded Shake the patient An obtunded gently as If opens patient eyes 3. Pulselessness awakening a sleeper, and looks at you 4. Paresthesia and responds 5. Poikilothermia (coldness) slowly and Is 6. Paralysis somewhat 2. HEMATOMA confused. Localized of clotted blood Alertness and Small size that occur during surgery is normal Interest In the environment are Large hematomas are serious complication that can decreased, Unable compromise circulation blood volume and cardiac Lo recall who, output. where he Is or the Uma of the Assess frequency after invasive cardiac procedure for acute vascular changes Stupor Apply a painful A stuporous stimulus. For patient arouses 3. EDEMA example, a pinch a from sleep only abnormal accumulation of fluid in the dependent areas tendon, rub and after painful sternum, or roll a stimuli. Verbal of the body pencil across a nail responses are bed. (No stronger slow or even PERIPHERAL EDEMA stimuli needed). absent. Edema of the feet, ankle and legs Common finding in patient with HF, Peripheral vascular The patient lapses disease (vein thrombosis) into an unresponsive state when the stimulus ceases SACRAL EDEMA There is minimal On the sacral area can be awareness of self observe at rest or the environment Coma Apply repeated A comatose painful stimuli patient remains un-arousable with eyes closed. PITTING EDEMA There is no Describe indentation of the evident response skin created by the pressure to inner need or external stimuli ASCITES Is the abnormal buildup of fluid in the abdomen ASSESSMENT OF THE SKIN AND EXTREMITIES ASSESS - Skin color ANASARCA - Temperature and texture General swelling of the whole body 1. Signs and symptoms of acute obstruction of arterial blood flow in the extremities 6 P`s 1. Pain Hennessy Shaina Fabiculana PROLONG CAPILLARY REFILL: Indicates inadequate arterial perfusion to the extremities - Compress the nail bed briefly to occlude perfusion and the nail bed blanches - Normal 2 seconds CLUBBING OF THE FINGERS AND TOES Indicates chronic hgb desaturation associated with the congenital heart disease. NOTE: A prolonged capillary refill time may be a sign of shock, indicates dehydration or a sign of dengue hemorrhagic fever and decreased peripheral perfusion. Prolonged capillary refill time may also suggest peripheral artery disease PERIPHERAL NEUROPATHY Is a damage or dysfunction of one or more nerves that typically results in numbness, tingling, muscle weakness and pain in the affected area. - Neuropathies frequently start in the hands and feet, but other parts of the body are affected too. EXAMPLES OF HEART ABNORMALITIES ASSESSING CHEST PAIN - The heart as pump (reduced pulse pressure, displaced PMI from the 5th ICS, midclavicular line, gallop sounds and murmurs) - Atrial and ventricular filling volumes and pressures (elevated jugular venous distention, peripheral edema, ascites, crackles and postural changes in BP) - Cardiac output (reduced pulse pressure, hypotension, tachycardia, reduced urinary output, lethargy or distension) - Compensatory mechanism (peripheral vasoconstriction and tachycardia) ASSESSMENT OF THE SKIN AND EXTREMITIES Indication of chronically reduced oxygen and nutrients supply to the skin in patient with arterial and venous insufficiency - Hair loss - Brittle nail - Dry or scaling skin - Atrophy of the skin - Skin color changes - ulceration Hennessy Shaina Fabiculana  POSTURAL (ORTHOSTATIC) HYPOTENSION BLOOD PRESSURE - Sustained decrease of at least 20 mmhg in SBP and Systemic arterial BP is the pressure exerted on the 10 mmhg in DBP within 3 minutes moving from walls of the arteries during ventricular systole and lying to sitting to standing position diastole Supine: Factors that affect blood pressure - BP 120/70 mmHg, heart rate 70 bpm - Cardiac output Sitting: - Distension of the arteries - BP 100/55 mmHg, heart rate 90 bpm - Volume, velocity and viscosity of the blood. Standing: - BP 98/52 mmHg, heart rate 94 bpm HYPERTENSION Having BP that is consistently higher than 140 mm Hg ARTERIAL PULSES or diastolic greater than 90 mm Hg - The arteries are palpated to evaluate the pulse rate, HYPOTENSION rhythm, amplitude, contour and obstruction to Abnormally low blood systole and diastole can be result blood flow in light-headedness or fainting Factors to be evaluated in examining the pulse rate PULSE PRESSURE - Rhythm - Quality - The difference between the systolic and diastolic - Configuration of the pulse wave pressures - It is a reflection of stroke volume, ejection velocity and The normal pulse rate varies from a low of 50 bpm in systemic vascular resistance healthy - Normal is 30 to 30 mmHg Anxiety frequently raises the pulse rate during - Increases in conditions that elevate the stroke physical examination volume If the rate is higher than expected, it is appropriate to Anxiety reassess it near the end of the physical examination, Exercise when the patient may be more relaxed Bradycardia NORMAL PULSE RATE - Reduce systemic vascular resistance Fever or reduced distensibility of the arteries AGE HEART RATE (beats per Atherosclerosis, aging and hypertension minute) NOTE: Pulse pressure less than 30 mmHg signifies a serious Infant (6 months) 120-60 reduction in cardiac output and requires further cardiovascular assessment. Toddler (2 years) 90-140 Preschooler 80-110 POSTURAL BLOOD PRESSURE CHANGES School age 75=100 - gravitational distribution of approximately 300 ml to 800 ml of blood to the lower extremities and GIT upon Adolescents 60-90 standing - Normal response of the body when a person moves Adult 60-100 from lying to standing 1. HR Increases above 20 bpm above resting PULSE RHYTHM rate 2. Unchanged systolic pressure or slight degrees slight decrease: to 10 mmHg SINUS ARRHYTHMIA 3. Slight Increase In diastole up to 5 mmHg In PP - refers to a changing cycle, sinus node rate with the respiratory on Inspiration and expiration - The pulse rate, particularly in young people, increases during inhalation and slows during exhalation Hennessy Shaina Fabiculana  - if the pulse rhythm is irregular, the heart rate should be JUGULAR VENOUS PULSATION counted by auscultating the apical pulse for a full minute while simultaneously palpating then radial pulse. - Disturbances of rhythm (dysrhythmias) often result in a - Right-sided heart function can be made by observing pulse deficit difference between the apical rate (the the pulsations of the jugular veins of the neck heart rate heard at the apex of the heart) and peripheral This provides rate. - a means of estimating central venous pressure (CVP), which reflects right atrial or right ventricular PULSE DEFICITS end-diastolic pressure (the pressure - Commonly occur with the atrial fibrillation, atrial. flutter premature - Immediately preceding tho contraction of the right - Ventricular contractions and varying degrees of ventricle). heart block. - Obvious distension of the veins with the patients head elevated PULSE QUALITY OR AMPLITUDE - 45 degrees to 90 degrees Indicates an abnormal The numerical classification is quite subjective; Increase in the volume of the venous system. This is therefore, when documenting the pulse quality, ith helps associated with right-sided HF, to specify a scale range (e.g “left radial =3/ =4”) - less commonly with obstruction of blood flow in the superior vena cava, and rarely with acute massive pulmonary embolism PULSE AMPLITUDE JUGULAR VEINS 0-to -4 SCALE 0 - pulse not Palpable or absent NORMAL +1 weak thready pulse difficult to palpate, obliterated with pressure Not distended and non palpable +2 diminished pulse; cannot be obliterated The jugular venous pressure is usually assessed by +3 easy to palpate, full pulse; cannot be observing the right side of the patient's neck obliterated The normal mean jugular venous pressure, +4 strong bounding pulse may be abnormal determined as the vertical distance above the midpoint of the right atrium is 6 to 8 cm H2O. HEART INSPECTION AND PALPATION PALPATIONS OF ARTERIAL PULSES (Light palpation is essential) Examined indirectly by: Pulses are detected over 1. Right and Left temporal 2. Carotid 3. Radial and femoral 4. Popliteal 5. Dorsalis pedis 6. Posterior tibial arteries - inspection, palpation, percussion and auscultation of the chest wall (in the 6 areas) 1. Aortic area - 2nd ICS to the right of the sternum - Determine the correct ICS start at the angle of Louis NURSING ALERT: Do not palpate temporal or carotid arteries From this angle, locate target 2nd simultaneously because it is possible to decrease the blood flow to the brain intercostal space by sliding one Only for emergency matter finger to the left or right of the sternum 2. Pulmonic area - 2nd ICS to the left of the sternum Hennessy Shaina Fabiculana  - - Or a very high-pitched murmur heard best with the stethoscopes diaphragm 3. Erb`s point - 3rd ICS to the left of the sternum NOTE: Important to remember which lesions results in systolic murmurs and which result in diastolic murmurs 4. Right ventricular or tricuspid area Stenosis of the aortic or pulmonic valves will result in systolic - 4th and 5th ICS to the left of the sternum murmur as blood is ejected through the narrowed orifice 5. Left ventricular or apical area QUALITY - The PMI, location on the chest where heart - The character of the sound contractions can be palpated - A murmur may be described as rumbling, blowing, whistling, harsh or musical 6. Epigastric area- - Below xiphoid process RADIATION Can radiate into the MURMURS - Axilla - Carotid arteries TIMING - in cardiac cycle is vital - Neck The examiner: - Left shoulder and back - First determine if occurring in systole or diastole - begin simultaneously with a heart sound or is there FRICTION RUB some delay between the sound and the beginning of the murmur? - A harsh, granting sound that can be heard in the both - Murmur continue to (or through) the second heart systole and diastole sound, or is there a delay between the end of the - Caused by abrasion of the pericardial surfaces murmur and the second heart sound? during the cardiac cycle, - A pericardial friction rub can be heard best using INTENSITY the diaphragm of the stethoscope with the patient - Is graded through I through VI sitting up and leaning forward. ASSESSMENT OF THE OTHER SYSTEMS Grade I Are difficult to hear, very faint Grade II Quiet can be easily perceived LUNGS by the experienced examiner. 1. HEMOPTYSIS Pink, frothy sputum is indicative of acute Grade III Moderately loud pulmonary edema 2. COUGH Grade IV Or louder are usually A dry cough from irritation of small airways is associated with thrills that common in patients with pulmonary may be palpated on the congestion from heart failure surface of the chest wall. 3. CRACKLES HF or atelectasis associated with bed rest, Grade V - Can be heard with the splinting from ischemic pain stethoscope partially of effects of pain medications and sedatives from chest, Associated with thrill results In the development of crackles First noted at the bases (but they may Grade VI- Extremely loud; detected with progress all portions of the lung fields) the stethoscope 4. WHEEZES off the chest associated. with Compression of the small airways by thrill to its interstitial pulmonary edema may cause conclusion. This is very wheezing characteristic of certain Beta-adrenergic blocking agents (beta- blockers), (as propranolol (Inderal) may precipitate airway narrowing, especially in PITCH patients with underlying pulmonary disease - Its pitch, which may be low often heard only with the 5. ABDOMEN bell of the stethoscope placed lightly on the chest wall Hepatojugular reflex Hennessy Shaina Fabiculana  Liver engorgement Occur early in diastole, during the rapid-filling phase of the - Occurs because of decreased cardiac cycle, or later at the time of atrial contraction. "Lub- venous return secondary to right dub-DUB" ventricle failure The liver is enlarged, firm , non tender and smooth In older adults, it may indicate heart disease. ( An S4 gallop is an extra sound before S1 systole “lub” 6. BLADDER DISTENTION sound) Its always a sign of disease, likely the the failure of Caused by urinary retention the left ventricle of your heart - When the urine output is decreased, SUMMATION GALLOP the patient needs to be assessed for a distended bladder or difficulty - Four sound (quadruple rhythm) combine into loud voiding. sound - A right sided S4 although less common heard over Abdominal distention the tricuspid area when client is in supine position - A protuberant abdomen with bulging frank and heard during tachycardia ascites - “LUB-lub-dub-DUB” - Develop in a patient with right ventricular heart failure OPENING SNAPS AND SYSTOLIC CLICK NORMAL HEART SOUND Diseased of the valve leaflets creates abnormal sounds as they open during diastole The 1st heart sound (S1) is produced by the closing of the MV and TV and is best heard at the apex of OPENING SNAPS the heart (left ventricular and apical area) The 2nd heart sound (S2) is produced by the closing Abnormal diastolic sound (high-pitched) caused by of the AV and PV is loudest at the base of the heart. pressure in in the LA heard during opening of the AV The time between S1 and S2 corresponds to systole valve (ex: mitral stenosis) The time between S2 and S1 Is diastole SYSTOLIC CLICKS ABNORMAL HEART SOUND One of the semilunar valves creates a short high - These sounds are called S3 and S4 gallops,gallops, pitched sound early in systole immediately after S1 snaps, or clicks. caused by a very high pitched pressure within the - Significant narrowing of the valve orifices at times when ventricle, displacing a rigid and calcified aortic they should be open, or residual gapping of valves at valve times when they should be closed, gives rise to prolonged sounds called murmurs MURMURS ABNORMAL HEART SOUNDS are created by the turbulent flow of blood Causes S1 (e.g., mitral stenosis, atrial fibrillation) - critically narrowed blood S2 (e.g., hypertension, aortic stenosis) - A malfunctioning valve that allows regurgitating blood S3 (e.g., congestive heart failure) flow S4 (e.g, hypertension) - a congenital defect of the ventricular wall, a defect Abnormal splitting (e.g., atrial septal defect) between the aorta and the pulmonary artery An increased flow of blood through GALLOP SOUND - a normal structure (eg, with fev hyperthyroidism). - If the blood filling the ventricle is impeded during NOTE: diastole, a temporary vibration may occur in diastole - Heart murmurs are described in terms of location, - Is similar to, usually softer than, S1 and S2. timing, intensity, pitch, quality and radiation These characteristics provide data about the location and nature - come in triplets and have the acoustic effect of a of the cardiac abnormality. galloping horse AUSCULTATION PROCEDURE Hennessy Shaina Fabiculana  - During auscultation, the patient remains supine and the - CK isoenzymes (CK-MB) examining room is as quiet as possible Proteins (myoglobin, troponin T and TROPONIN I) - A stethoscope with a diaphragm and a bell is necessary leak into the interstitial spaces of the for accurate auscultation of the heart. myocardium--carried Into the general circulation (lymphatic system)- and the coronary circulation, Care of clients with problems in - Oxygenation resulting in elevated serum enzyme concentrations. (Cardiovascular, Peripheral Vascular, Lymphatic and — Blood Disorders) DIFFERENTIATION Creatine Kinase (CK) and its Isoenzyme CK-MB DIAGNOSTIC EVALUATION most specific enzymes analyzed in acute MI, LABORATORY TEST 1st enzyme levels to rise. Lactic dehydrogenase and its isoenzymes also PURPOSE: are analyzed in patients who have delayed - To assist making in diagnosis seeking medical attention, because these - To screen for risk factor associated with CAD blood levels rise and peak in 2 to 3 days, - To determine baseline values before initiating other much later than CK levels. diagnostic tests, procedures or therapeutic interventions Myoglobin - To monitor response to therapeutic interventions - To assess for abnormalities in the blood that affect an early marker of MI, prognosis is a heme protein with a small molecular weight. INDICATION: Reason to be rapidly released from damaged - To assist in diagnosing an acute MI myocardial tissue - To identify abnormalities in the blood that affect the early rise, within 1 to 3 hours after the onset of prognosis of a patient with a cardiac condition an acute MI. peaks in 4 to 12 hours and - To assess the degree of inflammation returns to normal in 24 hours. - To screen for risk factors associated with not used alone to diagnose MI, because atherosclerotic coronary artery disease elevations can also occur in patients with renal - To determine baseline values before performing or musculoskeletal disease. therapeutic interventions - To monitor serum levels of medication - To assess the effects of medications (e.g. the effects of Troponin I diuretics on serum potassium levels) - To screen generally for abnormalities Advantages Troponin I is a contractile protein found only in cardiac muscle. After myocardial injury CARDIAC BIOMARKER (ENZYME) ANALYSIS Elevated serum concentrations can be detected within 3 to 4 hours Diagnosis of M.I is made by: Peak in 4 to 24 hours and remain elevated for - Evaluating health history, physical examination 1 to 3 weeks. (symptoms) These early and prolonged elevations make - Electrocardiogram (ECG) very early diagnosis of MI possible or allow for - Result of laboratory test that measure the serum late diagnosis if the patient has delayed cardiac biomarkers seeking treatment. low cut-off point (0.1 ng/ml) is the most Measured to evaluate heart function mostly myocardial infarction but other conditions can lead to an elevation reliable in cardiac levels Most of the early makers identified were enzymes and MOST RELIABLE LABORATORY TEST FOR MYOCARDIAL as a result, the term cardiac enzymes INFARCTION SERUM CARDIAC BIOMAKERS MYOCARDIAL CELL necrotic from prolong ischemia or trauma--release: - Specific enzyme (Creatine kinase (CK) Hennessy Shaina Fabiculana  BLOOD CHEMISTRY, HEMATOLOGY AND harmful effect COAGULATION STUDIES - Deposition of these substances in the walls of arterial vessels. Lipid Profile - Elevated levels are associated with a greater incidence of CAD in people with known CAD Cholesterol, triglycerides and lipoproteins or diabetes are measured to evaluate a persons risk for developing atherosclerotic disease and CAD PRIMARY GOAL: for lipid management is reduction of LDL There is a family history of premature heart levels to less than 100 mg/dL disease or to diagnose a specific lipoprotein abnormality “ BAD CHOLESTEROL” Lipoproteins High- density lipoproteins (HDL) Form when cholesterol and triglycerides are normal range transported in the blood by combining with - men 35 to 70 mg/dL protein molecules - women, 35 to 85 mg/dL Referred to: Have a protective action. Low density lipoproteins - They transport cholesterol away from the (LDL) tissue and cells of the arterial wall to the liver High density lipoproteins for excretion. (HDL) “ GOOD CHOLESTEROL” The blood specimen for the lipid profile should be obtained after a 12-hour fasting Factors that lower HDL levels CHOLESTEROL LEVELS - Smoking - Diabetes CHOLESTEROL - Obesity - Normal level, less than 200 mg/dL - Physical inactivity - A lipid required for hormone synthesis and cell In patients with CAD, a secondary goal of lipid management is membrane formation. the increase of HDL levels more than 40 mg/dL - It is found in large quantities in brain and nerve tissue. Triglycerides TWO MAJOR SOURCE OF CHOLESTEROL normal range, 100 to o 200 mg/dl Are diet (animal products) Composed of free fatty acids and glycerol are stored Liver where cholesterol is synthesized in the adipose tissue and are a source of energy Elevated cholesterol levels are known to increase the risk of CAD Triglyceride level increase: - After meals ○ Age - Stress ○ Gender - Diabetes ○ Diet - Alcohol use ○ Exercise - Obesity ○ Patterns - genetics These levels have a direct correlation with LDL and inverse one - menopause with HDL - tobacco use - stress levels. Low- density lipoproteins (LDL) Normal level is less than 160 mg/dl Hennessy Shaina Fabiculana  LIPID PROFILE Test to determine if a person has a vitamin B12 or folate deficiency. DESIRABLE BORDERLINE HIGH RISK The homocysteine concentration may be elevated before B 12 and folate tests are abnormal High risk- greater than 15 mmol/L Cholesterol