Cardiovascular and Peripheral Vascular Systems PDF

N304 Cardiovascular, Peripheral Vascular and Lymphatic Systems  Cardiovascular System § Location of the heart §Mediastinum/Mediastinal space §Between the 2nd and 5th intercostal space §R sternal border to the L midclavicular line § Precordium  Cardiovas...

N304 Cardiovascular, Peripheral Vascular and Lymphatic Systems  Cardiovascular System § Location of the heart §Mediastinum/Mediastinal space §Between the 2nd and 5th intercostal space §R sternal border to the L midclavicular line § Precordium  Cardiovascular System Heart Wall § Pericardium § Fibrous sac surrounds and protects the heart. § Parietal § Visceral (epicardium) § Pericardial fluid between the parietal and visceral layers § Allows for friction free movement 5  Cardiovascular System Heart Wall n Myocardium – Muscular wall of heart – High oxygen demand – Pumping action n Endocardium – Layer of endothelial tissue which lines the inner surface of the heart chambers  Cardiovascular System 4 Chambers of heart (2 atria & 2 ventricles) nSeparated by valves and septum nAtria—Receive blood from major blood vessels and pump into the ventricles – RA-unoxygenated blood from systemic system Superior and Inferior Vena Cava – LA-oxygenated blood from pulmonary veins  Cardiovascular System 4 Chambers of heart nVentricles—Receive blood from atria and eject blood into vessels leaving the heart. – RV-unoxygenated blood to the lungs via pulmonary artery – LV-oxygenated blood to the body via the aorta  Cardiovascular System 4 Valves – Unidirectional in healthy heart – Atrioventricular valves (AV) – Separate Atria and Ventricles § 1. Tricuspid on Right § 2. Mitral (Bicuspid) on Left § Open during heartʼs filling phase (diastole) § Close with ventricular contraction (systole) – Prevent regurgitation of blood back to atria  Cardiovascular System Semilunar valves (SL) Separate ventricles and arteries 3. Pulmonic on Right 4. Aortic on Left Open during ventricular contraction/rising pressure within ventricles (systole) Close with ventricular relaxation 12  The Cardiac Cycle Diastole & Systole n Ventricular Filling/Diastole – Ventricular relaxation/fill with blood – Early diastole § Blood rushes into ventricles from atria through AV valves (75% ventricular volume) – Late diastole § Atrial kick-contraction of atria pushing last blood into ventricles. 25% of ventricular volume  The Cardiac Cycle Diastole & Systole n Ventricular Systole – Ventricular pressure rises to level higher than atrial pressure § AV valves close/S1 – Ventricles contract § SL valves open/ blood forced out into pulmonary and systemic circulation § Ventricular pressure falls § SL valves close/S2  Heart Sounds n S1--Closure of AV valves – beginning of systole – ventricles are full – loudest at apex n S2--Closure of semilunar valves – end of systole – ventricular pressure decreases – Pressure higher in aorta/pulm artery – loudest at base 15 14  Heart Sounds Effect of Respiration n SplitS2 n During inspiration § Right side § Increased venous return § Increased stroke volume delays pulmonic valve closure § Left side § Decreased blood return § Decreased stroke volume hastens aortic valve closure 16 15  Cardiovascular System Extra heart sounds nS3 – Early diastole – Heard right after S2 – Ventricles resistant to filling cause vibrations – Caused by ventricular overload as in heart failure, pregnancy – https://www.youtube.com/watch?v=1B6dUwDJ3uo n S4 – End of diastole – Heard just before S1 – Blood pushed by atrial kick into non compliant or stiff ventricle, coronary artery disease, cardiomyopathy, afterload obstruction May be normal finding in elderly https://www.youtube.com/watch?v=gZ6zJVQXPH8  Heart Sounds Murmurs--Turbulent blood flow – Increased blood velocity – Decreased blood viscosity – Valve defects or unusual openings in chambers § Stenosis § Regurgitation https://www.youtube.com/watch?v=aGLT Jduxwvw 18  Electrical Conduction of Heart n SA Node – Initiates electrical impulse “pacemaker” n Transmits impulse to atria n AV Node – Slows conduction slightly--so atria can contract n Bundle of His, bundle branches, Purkinje fibers n Ventricles Electrical Impulse Conduction https://www.youtube.com/watch?v=RYZ4daFwMa8 20  Important Words n Depolarization – Spread of the electrical current – Causes contraction of cardiac muscle – Corresponds to Systole n Repolarization – Cells return to negatively charged state – Heart is at rest – Correspond to Diastole n Diastole – Chambers are at rest n Systole – pumping of the heart (mostly refers to ventricles) 21  Electrical Impulse Conduction P wave-depolarization of atria PR interval-Time it takes for impulse to travel from atria to ventricles QRS-Depolarization of ventricles T wave-Repolarization of ventricles.  The Heart As A Pump n Cardiac Output (CO) – Amount of blood ejected x 1 minute – 4 - 6 Liters of blood per minute – stroke volume x heart rate for 1 minute  The Heart As A Pump n Preload – amount of blood available to flow into the ventricles /venous return during diastole – Ventricular stretching just before contraction n Afterload – pressure heart must push against with ventricular contraction/systole  Cardiovascular System n Carotid Artery – Directly from aorta blood to head (brain) – Groove between trachea and sternomastoid muscle n Jugular Veins – Unoxygenated blood directly into SVC. Indicator of pressures on R side of heart 26  Hemodynamic Changes with Aging n Stiffening of arteries cause increase in systolic blood pressure n Increased left ventricular size n Increased pulse pressure § Diastolic remains the same but systolic pressure may increase due to afterload increase n Decreased ability of heart to increase CO with exercise and stress n Dysrhythmias n ECG changes n CV disease risk increases  Peripheral Vascular System Arteries § Arterial walls are strong § Elastic tissue and smooth muscle § Allows them to stretch § Oxygen rich blood to system § Pulse § expand and recoil due to pressure wave § Obstruction of artery causes ischemia to tissue below  Arteries n Arterialpulses are palpable when artery lies close to body surface – Brachial – Radial – Ulnar  Arteries n Femoral n Popliteal n Dorsalis pedis n Posterior tibial 30 32  Venous System § Deoxygenated blood back to heart § Low pressure system/No pump § Venous return relies on § Contraction of skeletal muscles (movement) § Intraluminal valves (one way valves) § Pressure changes with respirations § Thinner walls § Can dilate to accommodate greater volume § Stasis blood pooling during overload, or with valve problems-  Veins n Deep Veins – Femoral and popliteal – Carry ~ 90% venous return from lower extremities n Superficial Veins – Great and small saphenous – Most susceptible to stasis n Perforators – connect deep veins to superficial veins  Lymphatic System n Extensive vascular network that drains lymph from bodily tissue and returns it to venous circulation 1. Conserves plasma proteins 2. Plays major role in immune system 3. Lipid absorption from intestinal tract  Lymphatic System Lymph nodes nImportant role in body’s immune system nCells in lymph nodes engulf cellular debris/bacteria and produce an antigen response nNodes become swollen and tender with local inflammation nOnly superficial lymph nodes accessible to physical examination nGenerally not palpable on healthy adults 34  Subjective Assessment/Cardiac n Chest pain n COLDSPA n Dyspnea – With exertion? Dyspnea on Exertion (DOE) – Awaken from sleep?/Paroxysmal Nocturnal Dyspnea (PND) – When lying?/Orthopnea – How many pillows?  Subjective Assessment/Cardiac § Cough § Productive? § Fatigue § Cyanosis or pallor § Edema § Swelling equal bilaterally? § Swelling disappear after rest? § Nocturia  Subjective Assessment/Cardiac n Cardiovascular disease – Heart attack, CHF, chest pain, arrhythmias, valvular problems – Disease in family § Heart attack or stroke before the age of 50 n Diagnostics – EKG – Cardiac Cath n Cardiac surgery  Subjective Assessment/Cardiac n History of: n Hypertension n Diabetes n Bacterial or viral infections  Subjective Assessment/Cardiac § Personal health habits § Smoking § Second-hand smoke § Nutrition § Exercise § Alcohol/drug use § Medications § Over the counter meds  Subjective Examination/PV n Circulation – Cold, numbness, pallor in legs § Decreased circulation to lower extremities – hair loss – Edema § bilateral or unilateral – Claudication-pain with walking n Skin changes – Color/texture changes – Do veins bulge – sores § location  Objective Assessment/Cardiac n Inspection - Whole body for color - Extremities - Edema, color - Periorbital edema - Neck vessels - Jugular Vein Distention/JVD - 30-45 degree elevation of HOB - Carotid Arteries  Objective Assessment/Cardiac n Palpation/Carotid Artery – Keep the patient’s head elevated to 30° – Medial to sternomastoid muscle – Gently!!!!!!!!!! palpate the carotid upstroke – Never palpate simultaneously  Objective Assessment/Cardiac § Auscultation/Carotid Artery § Keep neck in neutral position § Ask patient to take in breath, exhale and hold it § Do not confuse heart sounds with bruit § Bruit § Loud blowing sound, Carotid Stenosis § Use bell of stethoscope  Objective Assessment/Cardiac n Jugular Venous Pulse Inspection n Inspect on person’s R side – External jugular vein § sternomastoid – Internal jugular vein § Sternal notch – Lie pt about 30-45°-no pillow – Turn pt head to side – Shine light on neck to see pulsations – Jugular veins flatten as the person is raised 44  Objective Assessment/Cardiac Precordium nInspect – pulsations--4th-5th ICS (Apical Impulse) nPalpate – Apical impulse--4th-5th ICS medial to MCL – palpate for thrills  Objective Assessment/Cardiac § Auscultation § 4 valve areas § 2nd R interspace § Aortic area § 2nd left interspace § Pulmonic area § L lower sternal border § Tricuspid area § 5th interspace L MCL § Mitral area § 3rd L interspace § Erb’s Point---S2 is loudest 46 50 Objective Assessment/Cardiac Auscultation – Note the rate and rhythm – Identify S1 and S2 in all areas with both bell and diaphragm – Assess S1 and S2 separately – Listen for extra sounds – Listen for murmurs § LSB/3rd or 4th ICS/Erb’s point/loudest S2 § L Midclavicular 5th ICS/mitral valve/loudest S1  Objective Assessment/Cardiac Extra Sounds n Listen for S1 or S2 splitting n Listen for S3 and S4 n Listen for murmurs § Grades i-vi--softest to loudest 48 52  Objective Examination/PV n Inspection/palpation – Upper Extremities § Edema of arms § obstruction of lymphatic system § Capillary refill § Delayed >2 seconds decreased CO, constriction of vessels, smoking, cold, anemia § Allen test https://www.youtube.com/watch?v=D1tJO0RW9UM  Objective Examination/PV n Inspection/palpation n Legs--MUST REMOVE SOCKS AND SHOES!! n Bilaterally § color, hair distribution § size, symmetry, swelling § venous pattern/venous enlargement § rashes, scars or ulcers § Superficial veins  Objective Examination/PV n Pulses/Bilaterally – Radial – Brachial – Femoral Pulse – Popliteal Pulse – Dorsalis Pedis Pulse – Posterior tibial pulse n Doppler Use  Objective Examination/PV n Assessing arterial pulses n Rate, Rhythm, Symmetry n Amplitude – 4+ Bounding – 3+ Increased – 2+ Brisk, expected – 1+ Diminished, weaker than expected –0 Absent, unable to palpate  Objective Examination/PV n Lymph Nodes/bilaterally – Epitrochlear – Inguinal  Objective Examination/PV Check for Arterial Deficit nLower extremity nRaiselegs 12 inches for 30 seconds/wiggle feet for about 30 seconds. § Color becomes paler nSit up and dangle legs nNote time it takes for color to return nNote time it takes for superficial veins around feet to fill § Color should return in 10 seconds or less § Veins should fill in 15 seconds or less § Extreme pallor and/or dark red bluish color – Arterial insufficiency  Objective Examination/PV § Lower extremity § Sensation § Arterial insufficiency § Diabetes/peripheral neuropathy § Edema/pitting edema § Press firmly § Look for pitting/depression § 1+ mild pitting § 2+ moderate pitting § 3+ deep pitting, leg appears swollen § 4+ very deep pitting, leg obviously swollen Figure 18.24 Grading pitting edema.  Objective Examination/PV n Lower extremity – Edema § Venous overload due to R heart failure § Occlusion of vein § Lymphatic problems § Fluid and electrolyte imbalance § Nutritional disturbances  Abnormalities Congestive Heart Disease – Inability of heart to be an effective pump – Left sided failure § Pulmonary edema – Right sided failure § Distended neck veins § Peripheral edema nPatients may have BOTH!  Abnormalities n Arrhythmias – Atrial fibrillation – Ventricular tachycardia – Ventricular fibrillation n Valves – Stenosis/narrowing – Regurgitation/incompetent Figure 17.37 Ventricle tachycardia. Figure 17.38 Ventricular fibrillation. Figure 17.41 Atrial fibrillation.  Abnormalities n Aneurysms n Aorta, abdominal, femoral, renal arteries n Weakened middle layer of vessel causing outpouching 63 67  Arterial Insufficiency n Pain and cramping § Pain and cramping in legs when walking or exercise § Improves with rest or dangling legs § Most common in calf n Skin – Cool, Pale, pulselessness, shiny, hairless  Venous Insufficiency – Aching, worse with standing or sitting – Pain mostly in calf – Feels achy, feeling of fullness – Swelling, varicose veins – Improved with elevation/walking. – Venous stasis ulcer 65