Structure of the Heart

Coronary Arteries
Electrophysiologic Properties
• Excitability- ability to depolarize in response
to stimulus
• Automaticity – ability of cardiac pacemaker
to initiate an impulse spontaneously and
repetitively
• Contractility- ability to contract
• Refractoriness- inability to respond to a new
stimulus while still in a state of
depolarization
• Conductivity- ability of heart fibers to
propagate electrical impulses along and
Cardiac Conduction System
Electrical Activity of the Heart
•Electrical impulses from your heart muscle (the myocardium) cause your
heart to beat (contract).

•S-A node (sinoatrial node)

•A-V node (atrioventricular node)

•Bundle of His

•Purkinje system
Electrical Pathway

STEP 1. The S-A node (natural pacemaker) creates

an electrical signal

STEP 2. The electrical signal follows natural electrical

pathways through both atria. The movement of electricity
causes the atria to contract, which helps push blood into the
ventricles
STEP 3. The electrical signal reaches the A-V node
(electrical bridge). There, the signal pauses to give the
ventricles time to fill with blood.

STEP 4. The electrical signal spreads through the

Bundle of His and Purkinje system. The movement of
electricity causes the ventricles to contract and push
blood out to your lungs and body
CO= SV x HR
• Control of heart rate
– Autonomic nervous system and baroreceptors

Autonomic Nervous System Affectation of

the CVS
• 1. Parasympathetic – Release of
Acetylcholine
• 2. Sympathetic – Release of Norepinephrine
Control of Stroke Volume

•Preload: Length of the myocardial fiber of the left ventricle

at the end of diastole
Frank-Starling law – The greater the myocardial
fiber length, the greater the force of contraction

•Afterload: The amount of pressure required by the left

ventricle to open the aortic valve during systole and to eject
blood
:affected by systemic vascular resistance and
pulmonary vascular resistance

*Contractility is increased by catecholamines (Adrenal

medulla), SNS, some medications and decreased by
hypoxemia, acidosis, some medications
 ASSESSMENT of the
CARDIOVASCULAR SYSTEM
I. Risk Factors
A. NON-MODIFIABLE RISK FACTORS
1. AGE
• 55 y/o. Effects of Age- related changes in cardiovascular
sx become more pronounced
• Symptomatic C.A.D. appears predominantly in clients
over 40y/o
• Clients in their 30’s, and even in their 20’s sometimes
suffer from anginal attacks or M.I
• 50% of  Attacks occur in individual >65y/o
2. GENDER
• Men are at a greater risk for the development of CVD
• Risk for women increases significantly at menopause

3. RACE
• Black Americans have a higher risk for developing CVD
than the general population because of their high
incidence of HPN.

4. FAMILY HISTORY
• The presence of Coronary Atherosclerosis in a parent or
sibling under 50y/o is associated w/ the same findings in
another family member.
B. MODIFIABLE RISK FACTORS
1. CIGARETTE SMOKING
• Major contributing factor of CVD
• ♂ adult smokers have a 70% higher
mortality rate than ♂ non-smokers
• All smokers have more than 2x the risk of
 attack than the non-smokers
• Smoking triples the risk of MI in women
and doubles the risk of MI in men.
2. HYPERTENSION
♂ over 45y/o and with BP ↑ 140/90 & adult ♀ w/
BP ↑ 160/95 have a 50% ↑ chance of mortality
HPN can be prevented through adherence to
medical regimen
3. ↑SERUM CHOLESTEROL (HYPERLIPIDEMIA)
Hyperlipidemia ↑es the risk of developing C.A.D.
among clients w/cholesterol level of >300mg/dl; is
3x more likely to develop C.V.D than in clients with
<200mg/dl of cholesterol level
A diet high in saturated fat, cholesterol and
calories is thought to be a major factor in the
development of hyperlipidemia
4. DIABETES MELLITUS
Diabetes leads to early atherosclerosis
Clients w/ DM are at much risk for CAD

5. OBESITY
↑ workload & O2 demand of the heart
Associated w/ ↑ed caloric intake and elevated levels of
LDL

6. LACK OF EXERCISE
Exercise can improve the efficiency of the 
Exercise may reduce the risk of CAD by ↓ weight, ↓ BP
& ↑ protective lipoprotein HDL
Sexual activity
7. STRESS
>Stress stimulates the CVS by the release of Catecholamines
Type A personality = found to have 2x risk of developing CVD
compared w/ the Type B person

8. ORAL CONTRACEPTIVES
Use of oral contraceptives or birth control pills has been
associated with an risk of CVD

9. DIET
Intake of food with ↑Na, Cholesterol, Saturated fat content &
caffeine
Nurse also assess attitudes toward food
Cultural beliefs and economic status can affect the choice of
food
10. HABITS
• Smoking (duration & the # of cigarette
sticks daily)
• Cigarette smoking ↑es the risk of CAD &
worsens hypertension
• Alcohol intake
 PHYSICAL EXAMINATION
• A general inspection
• Assessment of BP, arterial pulses, and
jugular venous pulse
• Percussion, palpation, and auscultation of
the heart
• Evaluation for edema
GENERAL APPEARANCE
Begin with inspection.
• Does the client lie quietly, or is there restlessness
or continual moving about?
• Can the client lie flat, or is only an upright, erect
position tolerated?
• Does the facial expression reflect pain or obvious
signs of respiratory distress?
• Are there signs of significant cyanosis or pallor?
• Can the client answer questions without dyspnea
during the interview?
LEVEL OF CONSCIOUSNESS
• What is the client’s affect?
• Are there obvious signs of anxiety, fear,
depression, or anger?
• How does the client react to those in the
immediate vicinity, including significant
others?

WEIGHT MANAGEMENT – daily weight,

height, waist circumference BMI
HEAD, NECK, NAILS, AND SKIN
• Pay particular attention to the eyes, ear lobes, lips, and
buccal mucosa.
– arcus senilis
– xanthelasma
• Central cyanosis indicates poor arterial circulation.
• Peripheral cyanosis, seen in lips, ear lobes, and nail beds,
suggests peripheral vasoconstriction.
• Blanch Test
• Schamroth’s Test
• Assess skin turgor (elasticity) by lifting a fold of skin
• Pallor
• PALLOR
– Result of inadequate circulating blood
– Characterized by the absence of underlying red tones
(browned skin – yellowish brown; black skinned –
ashen gray)
– Usually evident in areas least pigmentation:
conjunctiva, oral mucous membranes, nail beds, palms
of the hand, soles of the feet
• CYANOSIS
– Bluish discoloration of the skin
– Usually evident in the: nail beds and buccal mucosa (in
dark-skinned, assess the palpebral conjunctiva, palms
and soles)
■ EDEMA
-Inspect dependent areas for edema.

■ BLOOD PRESSURE
- Measure BP in both arms initially to rule
out dissecting aortic aneurysm,
coarctation of the aorta, vascular
obstruction, vascular outlet syndromes,
and errors in measurement.
 PULSE
-If the pulse is irregular, assess for a pulse deficit
0+ = nonpalpable pulse
1+ = weak thready pulse, difficult to palpate
+2 = diminished pulse, cannot be obliterated
+3 = easy to palpate, full pulse, cannot be obliterated
+4 = full bounding pulse

 RESPIRATIONS
-The rate, rhythm, depth, and quality of the breathing
pattern.
-Auscultate the lungs for the presence of crackles, rhochi
(dry rattling), or other abnormal breath sounds.
■ HEAD AND NECK
• Neck Veins
-Neck vein distention can estimate central
venous pressure (CVP). The amount of
distention reflects pressure and volume
changes in the right atrium.
• Carotid Arteries
-Check and compare the rate, rhythm, and
amplitude of the pulses.
-Note whether a bruit is present
■ CHEST
Precordium
-Perform inspection and palpation of the precordium
together to determine the presence of normal and abnormal
pulsations.
-The point of maximum intensity (PMI) or apical impulse is
usually seen at the apex.
-Right ventricular enlargement can produce an abnormal
pulsation that may be seen as a sustained thrust along the
left sternal border.

5 cardinal landmarks:
Aortic area – R 2nd ICS
Tricuspid Area -5th ICS L sternal border
Pulmonic area – L 2nd ICS
Erb’s point – 3rd L ICS
Apex – 5th ICS midclavicular line
Heart Sounds
-Note the quality (crisp or muffled), intensity (loud or
soft), rhythm (irregular or regular), and presence of
extra sounds (murmurs).

S1 – closing of AV valves, depolarization heard best

over the tricuspid and mitral area
S2 – closing of semilunar valves, repolarization,
heard best at aortic and pulmonic area
S3 – occurs in early diastole during rapid filling of
ventricles
S4 – occurs in later stage during atrial contraction
and active filling of ventricles
Pericardial Friction Rub
• Infammation of the pericardial sac by rubbing together of
visceral and parietal pericardium
• Best heard at the apex
• Scrathy, grating much like a squeky leather
• Accentuated when leaning forward or lies prone and
exhales

■LUNGS
Tachypnea
Tachypnea, or rapid respirations, is often associated with
pain and anxiety accompanying myocardial ischemic pain.
Crackles
Crackles are high-pitched, noncontinuous sounds.
■ ABDOMEN
Examination of the abdomen provides
information regarding cardiac competence.

Inspection and Palpation

-Inspection may reveal abdominal distention.
-Palpation may confirm the presence of ascites
and an enlarged liver.

Auscultation
Loud bruits, heard with the bell just over or
above the umbilicus, may indicate an aortic
obstruction or aortic aneurysm
SYMPTOM ANALYSIS
6 Cardinal Symptoms of CVD
• Chest pain
• Irregularities of heart rhythm
• Respiratory Manifestation
• Syncope
• Fatigue
• Weight gain and dependent
edema
Assessing Chest Pain
Chest pain
-Timing
-Quality
-Quantity
-Location
-Precipitating Factor
-Relieving Factor
-Associated Manifestaton
 ANGINA MI
TIME: 5-15 MINS 30 MINS

QUALITY:

SEVERITY: MILD SEVERE

LOCATION: Retrosternal (Left-sternum)Radiates

bilateral(arms, neck
& jaw) but usually to the left side

RELIEVING FX: REST, NITROGLYCERIN, O2

B. IRREGULARITIES OF HEART RHYTHM –
PALPITATIONS
-derived from the Latin palpitare, “to throb.” Palpitations
are uncomfortable sensations in the chest associated with
wide range of dysrhythmias.
- Question the client about
(1) medications;
(2) the frequency of palpitations, precipitating factors, and
aggravating or relieving factors; and
(3) any manifestations such as dizziness or shortness of
breath associated with the onset of the palpitations.
-Nervousness, heavy meals, lack of sleep, large intake of
coffee, tea, alcohol, tobacco, anemia, thyrotoxicosis
 RESPIRATORY MANIFESTATIONS
DYSPNEA = defined as shortness of breath or labored
breathing.

1. EXERTIONAL DYSPNEA or Dyspnea on exertion (DOE)- Most

common.
-It occurs during mild to moderate exercise or activity and
disappears with rest.
2. ORTHOPNEA. Orthopnea (difficult breathing) results from an
increase in hydrostatic pressure in the lungs when the person is
lying flat and is relieved when the person assumes an upright or
semivertical position
-Ask clients what actions they take to facilitate breathing.
3. PAROXYSMAL NOCTURNAL DYSPNEA. Paroxysmal
nocturnal dyspnea (PND) is dyspnea during sleep that awakens
the sleeper with a “terrifying breathing attack.”
D. SYNCOPE - or fainting, is a transient loss of consciousness related
to inadequate cerebral perfusion.

E. FATIGUE - Easy fatigability on mild exertion is a frequent problem

for clients experiencing cardiac disease;

F. WEIGHT GAIN AND DEPENDENT EDEMA

-As the heart fails, or the blood volume expands, fluid accumulates.
-Daily weight measurement is important for clients with cardiac
problems.

G. OTHER ASSOCIATED MANIFESTATIONS

g.1 Cyanosis is a subtle bluish discoloration.
-Blanch Test
g.2 Clubbing of the fingernails is seen in association with significant
cardiopulmonary disease.
-Schamroth’s test
g.3 Hemoptysis
Diagnostic Tests

Non – Invasive:

Nursing Responsibilities:

Explain the purpose and procedure to

the client; answer question.
Schedule of the test.
Perform any preliminary care.
Promote emotional and physical comfort.
Laboratory Tests
• Purpose:
– Diagnose a variety of cardiovascular
ailments
– Screen people considered at risk of CVD
– Determine baseline values
– Identify concurrent disorders
– Evaluate effectiveness of interventions
Preprocedures:

• Determine dietary restrictions before test

• Note time the drug was administered if to obtain
serum drug levels.
• Ask client if he/she is taking blood thinners such
as Warfarin Sodium (Coumadin)  delays
coagulation and requires longer time to hold
pressure over venipuncture site
• Gently invert lab tubes to prevent clotting of
specimens for CBC
• Apply pressure on puncture site.
CBC – ordered for all patients with documented or
suspected heart disease for evaluation of the overall health
status.
Cardiac enzymes – CK, LDH, Troponin

Myoglobin – released from the circulation within 1 to 2

hours of infarction. Not recommended if there is evidence of
muscle damage, trauma, or renal failure because of greater
potential for false positive lab results

Creatinine Kinase
3 isoenzymes:
CK MM
CK BB
CK MB – myocardial muscle, elevated within 6 to 8 after
onset of MI, maximum levels at 14 to 36 hours and returns to
normal after 48 to 72 hours. Samples should be taken
immediately on admission and every 6 to 8 hours for the first
24 hours.
Lactic acid dehydrogenase
Normal range: 100 to 225 mu/ml.
Onset: 12 hours
Peak: 48 hours
Duration: returns to normal in 10 to 14 days

Troponin (I, C, T)
I – modulates contractile state
C – binds calcium
T – binds I and C

Troponin I and T – cardiac specific

Onset: 4 to 6 hours
Duration – 4 to 7 days
Serum Lipids

Major Classes of Lipoproteins:

1. chylomicrons – composed mainly of triglycerides;
originated in the intestine
2. Very Low Density Lipoproteins – composed of
triglycerides; synthesized by the liver
3. Low Density Lipoproteins – 50% cholesterol
4. High Density Lipoproteins – composed mainly of
protein with a modest amount of cholesterol
Serum electrolytes:
– Potassium – NV: 3.5 to 5 mEq/L
– Hypokalemia – decrease level due to diuretic therapy,
vomiting, diarrhea, and alkalosis. Increases cardiac
electrical instability, characteristic U wave in ECG
– Hyperkalemia – associated with kidney disease, and
endocrine disorders. Characteristic tall T wave on
ECG.
– Sodium – NV: 135 to 145 mEq/L
– Calcium – NV: 4.5 to 5.5 mEq/L
– Hypocalcemia – can lead to serious ventricular
dysrhythmias, prolonged QT interval and cardiac
arrest.
– Hypercalcemia – shortens the QT interval and causes
AV block, tachycardia, bradycardia, and cardiac
arrest.
 – Magnesium – NV: 1.5 to 2.5 mEq/L
– Hypomagnesemia – severe cadiac dysrhythmias including
ventricular tachycardia, and fibrillation
– Hypermagnesemia – hypotension, bradycardia, and
prolonged PR and wide QRS complex.
– Phosphorus - NV: 1.2 to 3.0 mEq/L
– Hypophosphatemia – same w/ hypercalcemia
– Hyperphosphatemia – same w/ hypocalcemia,

Blood Glucose
ECG – graphic representation
of the electrical forces within the
heart

12 lead ECG
Tracings:
P wave – depolarization of the
atria
PR interval – the time it takes
for the impulse to spread from
the atria to the ventricles
QRS complex – ventricular
depolarization
T wave – ventricular
repolarization
Preprocedures:
• Remove metal objects
• No pain or electricity
• Avoid stimulants such as coffee, tea, and smoking 30
minutes to 1 hour before the test.

During procedure:
– Attach the electrodes to the client’s skin
• Precordial leads:
– V1 (red) – 4 ICS right sterna border
– V2 (yellow) – 4 ICS left sternal border
– V3 (green) – in between 2 and 4
– V4 (brown) – 5th ICS MCL
– V5 (black) – 5th ICS anterior axillary line
– V6 (violet) – 5th ICS MAL
 • Limb leads:
– Left upper extremity – yellow
– Left lower extremity – green
– Right upper extremity – red
– Right lower extremity - black
– Connect the electrodes to the cable
– Instruct to lie still, breathe normally and refrain from
talking.

Post-procedure:
• Record client’s age, weight, and height and medications
being taken.
• Wipe off the gel from client’s skin
2. Signal average – used to detect impulses
called late potentials and if pt. is at risk for V-
tach that may result in sudden death

3. Holter Monitoring – can be worn for a day

or longer, used to detect dysrhythmias that
may not appear in routine ECG
Stress Test
– valuable tool in detecting and evaluating CAD

It involves:

Using controlled and carefully supervised exercise

Evaluating the coronary arteries

Nursing Responsibilities: (Prior to the Test)

• Inform the client about the purpose and risks of the exercise.
• Obtain a signed consent.
• Instruct not to eat or smoke for 2 to 3 hours before test,.
• No alcohol 4 to 6 hours before test
• Wear appropriate attire
• No strenuous activity 12 hours prior to test
• Take the baseline data: ECG at rest, HR – client must have a
detailed physical exam before testing. ECG is closely monitored
by a physician
Post procedure:
• Monitor BP, HR and rhythm strip fro at least 15 minutes
after or until ECG returns to baseline
• Avoid warm bath
Reasons for Terminating the Test:
• Chest pain of fatigue
• Greatly increased heart rate
• Severe hypertension
• Dyspnea
• Untoward s/sx of myocardial ischemia/heart failure.

d. Chest x-ray (PAL) – to determine the size, silhouette

and position of the heart
e. Echocardiography (2D Echo) –
• Based on the principles
of ultrasound
• Records the structure
and motion of a heart
area in relation to its
distance from anterior
chest wall
• Detects
cardiomyopathy,
valvular d/o, ischemia,
tumor and chamber
size
f. MRI
– provides the
best information
on chamber
size, wall
motion, valvular
function and
great vessel
blood flow
2. Invasive
Cardiac Catheterization
– involves the insertion of
a catheter into the heart
and surrounding vessels
to obtain detailed
information about the
structure and
performance of the heart,
valves and circulatory
system. May include the
studies of the right, left
side of the heart and
coronary arteries.
Indications:
• Confirm a diagnosis of heart disease and determine the
extent to which the disease has affected the structure and
function of the heart
• Determine congenital anomalies
• Obtain a clear picture of cardiac anatomy before heart surgery
• Obtain pressures within the heart chambers and the great
vessels (aorta & pulmonary artery)
• Measure blood oxygen concentration, tension and saturation
within the heart chambers
• Determine Cardiac Output
• Perform angiography for better coronary artery visualization
• Obtain endocardial biopsy specimens
• Allow infusions of fibrolytic agents directly into an occluded
coronary artery to restore coronary blood flow
2 types of Cardiac Catheterization
• Right Sided Catheterization

• Left Sided Catheterization

– The catheter can be passed retrograde
(backward) from the brachial and femoral
artery into the aorta and then to the left
ventricle
– Rarely during Right sided catheterization, the
middle or lower third of the atrial septum is
punctured and the catheter is passed
transeptally into the left atrium
• Angiography –
invaluable tool in
cardiac diagnosis and
offers a great
assistance in
understanding heart
and vessel disease.
Injection of contrast
agent via IV at the
desired locations
under study.
• CINE ANGIOGRAPHY – moving pictures
are obtained during cardiac
catheterization

• CORONARY ANGIOGRAPHY – contrast

material is directly injected to the coronary
arteries
• Hemodynamic Studies – pressures
provide information about blood
volume, fluid balance and how well the
heart is pumping. (CVP, Pulmonary
Artery Pressure, Cardiac output
measurement, Intra-arterial pressure
monitoring)
Central Venous Pressure
• It reflects the pressure under which
the blood is returned to the SVC & RA
• Determined by vascular tone, blood
volume, and the ability of the right side
of the heart to receive and pump blood
• Can be measured with a central
venous line placed in the SVC or a
balloon flotation catheter in the PA
• Normal CVP pressure is 2-12mmHg
Nursing Interventions
• HOB elevated at 45 degrees angle
• Straining, coughing or any activity that increases
intrathoracic pressure produces false high results
• Patients with ventilator – take readings at the point of
end expiration
• Check connections of catheter and attachments to
prevent air embolism
• Check dressing at insertion site to prevent infection
• To maintain patency of the system, a small amt of fld is
delivered under pressure at a constant rate of flow
• COMPLICATIONS: pneumothorax, phlebitis, air emboli,
fld overload, dysrhythmias, sepsis, and micro electric
shock
 Pulmonary Artery Pressure
• Determines the left ventricular pressure
• Can assist in determining when the left ventricle is
understretched, overstretched, or appropriately stretched.
Pulmonary Artery Catheter – provides continuous direct
monitoring of PA pressure
Has 4 lumen:
1. Proximal lumen – terminates in the right atrium, allowing
CVP measurement, fluid infusion, & venous access for bld.
samples.
2. Distal lumen – terminates in the PA & measure PA systolic,
diastolic & mean pressure, and pulmonary capillary wedge
pressure (PCWP) – indicator of left ventricular pressure
3. 3rd lumen – for inflation & deflation of balloon
4 . 4th lumen (thermistor port) – permits measurement of CO
Nsg. Resp:
• Explain that the procedure will be uncomfortable but not
painful
• Local anesthesia will be given at anesthesia site
• Catheter is inserted via percutaneous puncture at the
brachial, subclavian, jugular or femoral vein.
• When catheter is wedged, is the most accurate indicator of
left ventricular end-diastolic pressure or left ventricular
preload.
• Normal PCWP is 8-13 mmHg. Greater than 18-20mmHg
indicates ↑ left ventricular pressure (L-sided heart failure) –
may coincide with congestion. More than 30mmHg –
edema
Pulmonary Artery Catheter and
Pressure Monitoring System
Arterial Pressure Monitoring System
Intra-arterial Pressure
monitoring
• Common method of obtaining BP
measurements for acutely ill clients
• Provides continuous detection of
arterial BP via an indwelling catheter
for those with decrease CO,
fluctuating hemodynamic status, and
progressive peripheral
vasoconstriction
• Intraarterial readings are higher 10
mmHg than cuff BP readings
Nursing Interventions

• Before the procedure

– perform allens test
– Maintain aseptic technique
– Check neurovascular status q 2hrs

• After the procedure

– Apply 5min pressure
– Maintain intact dressings for 12hrs
 End of
Presentation!

Thank You!